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A  plea  and  a  plan  I'or  the  eradication  of  malaria 
throughout  the  "e stern  hemisphere. 


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A  PLEA  AND  A  PLAN 

FOR  THE 

ERADICATION  o/MALARIA 

THROUGHOUT  THE 

Western  Hemisphere 


By 
FREDERICK  L.  HOFFMAN,  LL.D. 

Statistician 

The  Prudential  Insurance  Company 

OF  America 


AN  ADDRESS 

Read  in  abstract  before  The  SouUjcrn  Medical  Association 

Tenth  Annual  Mwting 

Atlanta,  Georgia,  November  14,  1916 


A  Plea  and  a  Plan 

For  the  Eradication  of  Malaria 

Throughout 

The  Western  Hemisphere 


By  FREDERICK  L.  HOFFMAN,  LL.l). 
Statistician  Tiik  PiirntNTiAi.  Insitranck  Company  ok  America 


Urad  in  ahstrart  before 

The  Soiitlurni  Mtilit-al  AssiK-iation.  Tfiifli  Aiiniml  Mci-tintf 

Atlanta,  (ieor^cia,  NovcniluT  I i.  Ii»l«> 


1917 

PRUDENTIAL  PRESS 

NEWARK,  NEW  JERSEY 

U.  S.  A. 


TO 

THE  NATIONAL  COMMITTEE 
(of  the  united  states) 

ON 

MALARIA  ERADICATION 

Organized  Mat  10,  191t; 
In  Accordance  with  Article  39 

OF  THE  Final  Act  of  the 

Second  Scientific  Pan-American 

Congress 

Washington,  191G 


LIST  OF  SCIENTIFIC  PUBLICATIONS 

OF 
THE  PRUDENTIAI<  INSURANCE  COMPANY  OF  AMERICA 

Available  on  Request 


By  John  F.  Dryden: 

(i)  The  American  Type  of  Isthmian  Canal;  1906. 

(2)  Addresses  and  Papers  on  Life  Insurance  and  Other  Subjects;  1909. 

(S)  Uniform  Laws  and  Legislation  on  Life  Insurance;  1910. 

(4)  Industrial  Insurance,  Past  and  Present;  1912. 

By  Frederick  L.  Hoffman: 

(5)  History  of  The  Prudential  Insurance  Company  of  America,  1900. 

(6)  Rural  Health  and  Welfare;  191^. 

(7)  Exhibits  of  The  Prudential  Insurance  Company  of  America,    Inter 

national  Congress  of  Hygiene  and  Demography,  1912. 

(8)  The  Significance  of  a  Declining  Death  Rate;  1914. 

I'J)  The  Chances  of  Death  and  the  Ministry  of  Health;  1914. 

(10)  Practical  Statistics  of  Public  Health  Nursing  and  Community  Sicknes 

Experience;  1914. 

(11)  Industrial  Accidents  in  the  United  States  and  Their  Relative  Frequency 

in  Different  Occupations;  1914. 
{IS)  The  Mortality  of  the  Western  Hemisphere;  1915. 
(IS)  American  Public  Health  Problems;  1915. 
(IJt)  The  Documentary  History  of  Insurance;  1915. 
{15)  The  Mortality  from  Cancer  Throughout  the  World;  1916. 
{16)  The  Sanitary  Progress  and  Vital  Statistics  of  Hawaii;  1916. 
{17)  A  Plea  and  a  Plan  for  the  Eradication  of  Malaria,  1917. 
{18)  Facts  and  Fallacies  of  Compulsory  Health  Insurance;  1917. 

By  Frederick  S.  Crum: 

{la)  A  Statistical  Study  of  Measles;  1913. 

{2a)  A  Statistical  Study  of  Whooping  Cough;  1914. 

{So,)  Medical  Inspection  of  Schools — a  Factor  in  Disease-Control;  1915. 

lia)  Anthropometric  Table;  Children  Aged  Six  to  Forty-eight  Months;  1916 

{5a)  The  Mortality  from  Diseases  of  the  Lungs  in  American  Industry;  191( 

CHARTS 

/  Mortality  from  Cancer  (21  charts). 
//  Mortality  from  Tuberculosis  (21  charts). 
Ill  Mortality  from  Measles  (5  charts). 
IV  Mortality  from  Whooping  Cough  (4  charts). 

V  Mortality  from  Accidents  (7  charts). 
VI  Mortality  from  Typhoid  Fever  (1  chart). 
VII  Mortality  from  Infantile  Paralysis  (1  chart). 
VIII  Mortality  from  Diphtheria  (5  charts). 
IX  Mortality  from  Malaria  (4  charts). 
X  Mortality  of  United  States  and  Germany  (3  charts). 


A  Plea  and  a  Plan 

FOR  THE  Eradication  of  Malaria 

Throughout 

THE  Western  Hemisphere 


PART  I 
A  PLEA  FOR  ORGANIZED  ACTION 

PART  II 

A  PLAN  FOR  ORGANIZED  PREVENTION 
AND  CONTROL 

PART  III 

SOME  ESSENTIAL  STATISTICAL 
CONSIDERATIONS 


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PART  I 

A  PLEA  FOR  ORGANIZED  ACTION 

3.V  a  resolution  adopted  by  the  Second  Pan-American  Scientific 
ngress,  the  United  States  and  all  Pan-American  countries  obligated 
•mselves,  singly  and  collectively,  to  join  in  an  effort  to  eradicate 
larial  diseases  from  the  western  hemisphere.  However  difficult  and 
larently  impossible  the  task  at  the  present  time  may  seem  to  those 
familiar  with  past  achievements  in  disease  prevention,  there  can  be  no 
^stion  of  serious  doubt  in  the  mind  of  those  familiar  with  the  facts 
it  the  aim  and  end  in  view  will  be  achieved  in  due  course  of  time, 
lether  it  will  require  one  generation  or  ten  to  secure  measurably 
isfactory  results  will  depend  primarily  upon  the  hearty  and 
cient  cooperation  of  all  governmental  agencies,  federal,  state  or 
inicipal,  and  the  international  cooperation  of  all  the  principal  countries 
the  western  liemisphere,  in  which  the  disease  is  of  relatively  common 
•urrence.  Among  the  endemic  diseases  of  our  Southern  States 
laria  ranks  first  in  the  order  of  practical  importance,  and  the  amount 
suffering  caused  by  it  and  the  social  and  economic  losses  resulting 
m  it  far  exceed  those  of  all  the  other  endemic  diseases,  chiefly  pellagra 
1  hookworm,  but  also  amoel)ic  dysentery, leprosy  and  blackwater  fever, 
ving  out  of  consideration  for  the  time  being  whether  the  last  named 
»uld  not  properly  be  included  within  a  broad  definition  of  malarial 
eases  in  general  terms.  Hookworm  disease  unquestionably  is  of 
)rmous  importance,  but  its  eradication  is  less  difficult  than  the  com- 
tc  cliniiiialion  of  malarial  disease,  on  account  of  the  wider  dissemi- 
Lioii  and  the  more  insidious  nature  of  malaria  and  the  complicated 
ationship  between  the  mosquito  and  man.     The  fevers  of  the  South 

•  a  medical  subject  which  has  been  under  extended  consideration  from 

•  very  setllerneiit  of  the  coniitry,  and,  to  a  not  inconsiderable  extent, 
iifhern  medical  practice  and  maliirial  diseases,  obviously  or  obscurely, 
olve  each  other. 

The  literature  of  malaria  is  .so  enormous  that  it  hardly  serves  a 
•ful  purpo.se  to  refer  even  briefly  to  the  earlier  di.ssertations,  such  as 
lie  History,  Diagnosis  and  Treat nu'iit  of  the  Fevers  of  the  United 
ifes,"  by  Klislia  IJartlell,  of  wliicli  the  first  edition  was  printed  in 
17,  the  less  generally  known  "Observations  upon  the  .\uluninal 
vers  of  Savannah,"  by  Dr.  W.  C.  Daniel!,  Savannah,  IH-if),  and  the 
.ssical  treatise  on  "The  Most  Common  Di.seiuses  of  the  South," 
Thonip.son  McCiown.  IMiiladelphia,  IHIO,  in  which  the  congestive 
CIS   and   the   remittent    fevers   occupy  the  most    prominent    place. 


A  PLEA  FOR  ORGANIZED  ACTION 

Fenner's  "Southern  Medical  Reports"  contain  numerous  and  convincing 
illustrations  of  the  enormous  losses  caused  to  the  Southern  States 
by  the  prevalence  of  uncontrolled  malarial  fevers  during  the  period 
immediately  preceding  the  Civil  War;  and  the  medical  history  of  that 
great  conflict*  bears  mute  evidence  to  the  havoc  caused  by  malarial  dis- 
eases to  the  armies.  North  and  South,  because  of  the  fact  that  the 
underljang  causes  and  conditions  responsible  for  disease  frequency  were 
completely  misunderstood. 

Contrasting  these  earlier  inquiries  and  observations  of  the  foremost 
medical  men  of  the  period  with  modern  works  on  malarial  fevers  by 
Celli,  with  special  reference  to  Italy,  f  by  Ross,  by  Craig,  by  Thayer,  by 
Sternberg,  by  Henson,  by  Deaderick,  and  finally  by  the  group  of  ex- 
traordinary men  in  charge  of  the  sanitary  administration  of  the  construc- 
tion and  maintenance  of  the  Panama  Canal,  |  the  contrast  is  not  more 
striking,  nor  in  a  measure  more  indicative  of  a  promising  future,  than 
the  earlier  misconceptions  of  the  cause  of  tuberculosis  and  the  revolu- 
tion in  medical  and  sanitary  practice  following  the  immortal  discovery 
of  the  tubercle-bacillus,  by  Roljert  Koch.  In  1870,  C.  F.  Oldham,  M.  D., 
assistant  surgeon  of  the  Indian  forces,  and  a  fellow  of  the  Royal  Medical 
and  Chirurgical  Society,  wrote  a  monograph  entitled  "What  is  Malaria, 
and  Why  Is  It  Most  Intense  in  Hot  Climates."  His  attempted  ex- 
planation left  the  problem  unsolved.  Forty  years  later  the  Royal 
Society  published  the  reports  of  a  special  malaria  committee,  in  which, 
in  conformity  to  the  exacting  methods  of  modern  science,  the  true  fac- 
tors and  elements  of  the  disease  were  set  forth  with  admirable  precision 
and  completeness,  and  continued  the  work  with  a  series  of  eight  reports, 
ending  with  1903.  Step  by  step  a  new  science  of  preventive  medicine 
has  been  developed,  and  of  the  ever-increasing  group  of  preventable 
diseases,  malaria,  without  question,  ranks  first  as  the  most  obviously 
eradicable  of  all. 

The  earlier  speculations  concerning  the  mode  of  infection  have  been 
supplanted  by  exact  scientific  researches  regarding  the  true  mode  of 
transmission,  confirmed  by  subsequent  experience,  and  few  now  seriously 
question  the  conclusiveness  of  the  results.  The  mosquito  as  a  transmit- 
ting agent  is  to-day  the  recognized  causative  agent,  although  the  mosquito 
itself  is  not  the  cause,  as  is  frequently  assumed  to  be  the  case.  The 
parasite  which  develops  malaria  is  transmitted  by  the  mosquito  toman, 
and  if  the  mosquito  itself  is  not  infected  there  is  no  possibility  of  malaria 
causation.  The  mode  of  infection  is  thoroughly  understood,  and  the 
known  facts  about  the  mosquito  have  increased  to  the  extent  that  the 
subject  has  a  literature  of  its  own,  and  the  methods  of  individual  and 
public  malaria  prevention  are  now  common  knowledge,  however  little 
that  knowledge  may  be  publically  applied. 

♦"Medical  and  Surgical  History  of  the  War  of  the  Rebellion,"  Vols,  i-iii,  Washington,  1888.  See,  aLo, 
article  on  Malaria,  Index  Surgeon-General's  Library,  Vol.  x,  Washington,  1905. 

tSee,  also,  "Atlante  di  Demografia  Medica  d' Italia,"  by  Dr.  Enrico  Raseri,  Roma,  1906. 
{Proceedings  Canal  Zone  Medical  Association,  Vol.  i-viii,  Ancon,  Canal  Zone,  1908-1915. 

8 


A  PLEA  FOR  ORGAXIZED  ACTIOS 

As  stated  by  Sir  Ronald  Ross,  the  most  distinguished  authority  on 
malaria,  and  himself  the  discoverer  of  the  causative  agent,  or  of  the  trans- 
mission of  the  disease  by  mosquitoes,  "malarial  fever  is  perhaps  the  most 
important  of  human  diseases,  and  though  it  is  not  often  directly  fatal,  its 
wide  prevalence  in  almost  all  warm  climates  produces  in  the  aggregate 
an  enormous  amount  of  sickness  and  mortality."  In  times  past  malaria 
was  not  limited,  and  it  is  not  even  to-day  limited,  to  warm  climates,  as 
best  illustrated  in  the  "Essays  on  Fevers,"  by  Miner  and  TuUy,  pub- 
lished at  Middletown,  Conn.,  in  1823,  which  includes  an  extended  ac- 
count of  a  yellow-fever  epidemic  in  that  community,  however  incredible 
the  possibility  of  such  an  occurrence  may  appear  at  the  present  time. 
Remittent  fevers  in  the  Central  States,  in  the  prairie  regions,  along  the 
margins  of  the  Great  Lakes,  in  central  New  York  and  in  New  England, 
during  the  early  years  when  the  country  was  being  settled,  caused  a  heavy 
mortality,  an  enormous  amount  of  sickness  and  a  correspondingly  con- 
siderable economic  loss.*  By  the  settlement  of  the  land,  by  the  elimina- 
tion of  pools  of  standing  water,  by  the  drainage  of  swamps,  gradually, 
though  at  a  truly  lamentai)le  cost,  the  northern  section  of  the  United 
States  has  become  i)ractically  free  from  nudarial  infection.  There  is  still, 
however,  a  measural>le  remnant  of  malaria,  and  the  possibilities  of  a 
serious  outbreak  exist  in  every  community  where  the  anopheles  mosqui- 
toes prevail  to  a  considerable  extent. f  The  best  illustration  is  the  recent 
epidemic  in  Greenwich,  Conn.,  a  very  healthy  suburban  community  near 
New  York,  where,  because  of  municipal  negligence  and  private  indiffer- 
ence, the  evil  assumed  such  proportions  as  to  call  for  drastic  state  and 
even  governmental  interference.  +  In  the  great  interior  valley  of  Califor- 
nia malaria  prevails  in  many  localities  to  such  a  degree  as  to  prove  a 
serious  hindrance  in  the  development  of  otherwise  promising  localities, 

♦Sec  Annual  Ueporla  of  Ihc  MiiliiRan  State  Board  of  Health.  1874.  1875.  1870,  1881,  188*.  See,  also. 
"A  Systematic  Treatment  on  the  Principal  Diseases  of  the  Interior  Valley  of  North  jAmerica,"  Vol.  i,  by 
Daniel  Drake,  M.  D.,  Cincinnati.  1850. 

fAn  exceedingly  interrslinu  reference  to  the  occurrence  of  fevers  during  the  pioneer  period  of  Ihe  Central 
West  appears  in  a  report  on  tin-  niedicnl  lopoKrupliy  and  epidemic  diseaso  of  Illinois,  conlriliuted  to  the  Trans- 
actions of  the  American  .Medical  Association,  Vol.  xviii.  Ptiiladelphiu,  181(7,  reading,  in  part:  "The  te.«ti- 
mony  borne  by  the  early  explorers  and  settlers  of  the  state  of  Illinois  was  anything  but  flattering  to  its  character 
for  healthfulnes*  and  salubrity  .  .  .  Fevers  due  to  miasmalic  causes  were  "f  frightful  frequency  among  th« 
pioneers,  and,  to  no  inconsiderable  extent,. still  prevail  in  the  alluvial  bottoms  of  the  rivera." 

In  Ihc  .same  transactions  was  publi.shed  a  prize  e.vsay  on  Ihe  cause  of  interniitlent  and  remittent  fevers,  by 
J.  R.  HIack,  .M.  I).,  (if  Newark,  Ohio,  in  which  references  weur  lo  the  freipieney  of  intermittent  and  remittent 
fevers  in  the  gold  regions  of  California.  The  as.sumed  law  of  inten.sily  ami  fre((uency  occurrem-e  in  periodical 
fevers  is  staled  to  be  that:  "With  a  summer  mean  lemperalure  of  sixty  degrees,  and  upwards,  the  greater  the 
diurnal  oscillations  of  tempi-ralure  Ihe  greater,  caeleris  parilius,  will  be  Ihe  prevah-nif  of  autumnal  fevers,  and 
with  Ihe  increase  of  Ihe  mean  is  the  increased  suseepliliilily  lo  fluctuations;  Ihe  higher  the  mean  Ihe  smaller, 
comparatively,  Ihe  oscillation  re<iuisile  lo  priMluce  the  morbid  phenomena,  and  Ihe  more  intense  their  char- 
acter" (p.  457). 

}0f  special  value  in  this  connect  ion  are  Ihe  following:  A  Report  on  the  History  of  Inlermitlent  Fever  io  the  Ni« 
Haven  Region,  contributed  to  Ihe  Proceetlings  of  the  (,'iinneclicul  Molical  Society,  |H7<;  An  AcctiunI  of 
.Malaria  in  ( 'onneclicul.  Including  Observali ms  i>n  Malaria  in  (ireeiiwieh,  as  Karly  as  1811,  in  the  Fourth  An- 
nual Report  of  the  Stole  Hoard  «.f  lleallh  of  ( 'onneeliiul,  Hartford,  |H8<;  An  Account  of  Kpidemic  Intermit, 
lent  Fevers  in  Connecticut,  in  the  Fifth  Annual  Report  of  Ihe  CiiiiMeclieul  Stale  Hoard  of  Health.  Hartford, 
IHH.i;  A  S|Mcial  ReiH.rt  of  the  llrnllh  ( (fljcer  of  (Ire-nwich  for  IWK,  in  Ihe  Thirtx -second  ReiMirt  of  the  Coo- 
neclicut  Slate  Hoaril  of  Health.  Hartford.  lUl.i;  Obsi-rvalions  on  MostpiiUi  CondilDiis  and  .Muii^tiilo  Surveys 
in  Connecticut  in  1IM5,  in  Ih--  .\nnunl  Rr|i<>rl  of  the  Coiineclicul  .Xgricultural  FxperiiuenI  Station,  .New  Havco, 
1910;  an  exceedingly  interesting  e<iiiiiiiuiii<'ali<>ii  from  the  (irr<-n«ick  .Mixlical  .S.K-iely  was  publubed  in  lb* 
.New   York  ^/ub«,  January  Ml,  lt)|3. 

9 


A  PLEA  FOR  ORGANIZED  ACTION 

and  real-estate  values  are  correspondingly  depressed,  because  of  the 
natural  aversion  of  people  to  live  in,  or  to  remove  to,  obviously  un- 
heal thful  localities. 

Sickness  is  no  longer  looked  upon  as  inevitable  or  as  an  evil  to  be 
borne  without  complaint.  Ill-health  is  now  recognized  as  a  most  serious 
hindrance  to  the  highest  development  of  the  individual  and  of  the  people 
collectively  considered.  With  an  ever-increasing  economic  pressure  the 
necessity  for  the  elimination  of  ill-health-producing  conditions  has  be- 
come a  governmental  problem  of  the  first  order  of  importance,  and  in  no 
special  field  of  preventive  medicine  have  the  actual  results  of  governmen- 
tal interference  and  control  been  more  satisfactory  and  conclusive  than  in 
the  prevention  of  malaria.  Among  the  most  useful  summary  accounts 
of  what  has  actually  been  achieved,  attention  may  be  directed  to  the 
treatise  on  "The  Health  Progress  and  Administration  in  the  West 
Indies,"  by  the  late  Sir  Rupert  Boyce,  which  includes  some  very 
interesting  observations  on  education  as  a  prophylactic  factor  in  the 
West  Indies,  the  war  against  insect  pests,  the  law  against  stagnant 
water  in  some  of  the  West  Indian  colonies  and  finally  the  extension 
of  disease  by  modern  commercial  intercourse.  More  recent,  and 
still  more  instructive  and  conclusive,  is  the  work  on  "Rural  Sanitation 
in  the  Tropics,"  by  Malcolm  Watson,  being  an  account,  amplified  by  per- 
sonal observations,  of  what  has  been  achieved  in  the  prevention  of  malaria 
in  rural  sections,  chiefly  of  the  Malay  Archipelago,  the  Panama  Canal 
Zone,  British  Guiana,  etc.  Of  special  interest  and  value  in  this  work  are 
the  rules  and  regulations  for  estate  sanitation,  which  are  perhaps  best 
illustrated  by  the  practical  results  obtained  in  the  sanitary  administra- 
tion of  Hawaii,  chiefly  with  regard  to  the  sugar  plantations.*  The 
magnificent  hospitals  of  the  United  States  Rubber  Company  in  the  Dutch 
East  Indies  have  no  parallel  in  any  rural  section  of  the  southern 
United  States.  Rural  sanitation  and  malaria  prevention  in  the  South 
are  practically  equivalent  terms,  and  the  one,  broadly  speaking,  can 
not  be  achieved  without  the  other.  Malaria  prevention,  to  be  perma- 
nently successful,  however,  requires  the  most  complete  coordination  of 
governmental,  corporate  and  private  functions  and  efforts,  to  the  same 
extent  to  which  this  has  been  the  case  in  Panama,  where  practically  the 
whole  population  has  been  brought  under  almost  perfect  sanitary  control. 

Thus  far  on  the  mainland  of  the  United  States  we  have  not  developed 
a  well-considered  national  plan  for  malaria  eradication,  nor  have  we 
perfected  even  the  underlying  organization  for  an  effective  agitation  of 
the  question  as  a  matter  of  general  public  policy.  Our  schools  of  tropi- 
cal medicine  are  poorly  financed,  and  their  work  is  far  from  having 
attained  to  the  practical  importance  of  the  corresponding  efforts  of  the 
Liverpool  School  of  Tropical  Medicine,  which  has  sent  out  one  malaria 
expedition  after  another,  as  a  result  of  which  there  has  gradually  been 
brought  together  a  series  of  monographic  studies  of  actual  achievements 

*"The  Sanitary  Progress  and  Vital  Statistics  of  Hawaii,"  Prudential  Press,  Newark,  N.  J.,  1916. 

10 


A  PLEA  FOR  ORGAMZED  ACT  I  OX 

that  may  well  challenge  the  admiration  of  mankind.  Among  others,  the 
school  has  reported  on  the  malaria  expedition  to  Sierra  Ivcone,  by  Sir 
Ronald  Ross,  the  malaria  expedition  to  Nigeria,  by  Annett,  the  progress 
of  the  campaign  against  mosquitoes  in  Sierra  Leone,  by  Taylor,  the 
prevalence  of  malaria  in  Ismailia  and  Suez,  the  malaria  expedition  to 
Gambia,  the  sanitary  conditions  obtaining  in  Para,  and  finally  a  sugges- 
tive outline  of  tlie  practical  study  of  malaria  and  other  blood-parasite 
diseases.  AYith  vast  commercial  interests  to  the  south  of  us  in  countries 
seriously  hindered  in  their  physical,  social  and  economic  progress  on 
account  of  the  still  extensive  prevalence  of  malaria,  we  have  practically 
made  no  efforts  in  the  direction  of  extensive  scientific  research  deserving 
of  serious  consideration,  excepting,  of  course,  the  monumental  work 
carried  on  and  completed  under  the  direction  of  Major-General  W.  C. 
Gorgas  in  Panama. 

Regardless  of  our  greater  wealth  and  connnercial  necessity  we  have 
made  no  thoroughly  scientific  malaria  research  comparable  to  the  results 
rei)orted  upon  in  memoirs  by  officers  of  the  medical  and  sanitary  depart- 
ments of  the  Government  of  India,  including  monographs  on  malaria  in 
India,  by  Capt.  S.  P.James,  malaria  in  the  Punjab,  by  Maj.S.  R.  Christo- 
phers, reports  on  the  antimalarial  operations  at  Mian  Mir,  !)y  Capt.S.  P. 
James,  and  finally  reports  by  the  same  distinguished  authority  on  kala- 
azar,  malaria  and  malarial  cachexia.  It  is  true,  of  course,  that  malaria  in 
India  is  absolutely  of  the  very  first  order  of  practical  importance,  and  that 
any  measures  and  means  of  the  Government  of  India  in  the  direction  of 
malaria  prevention  are  certain  to  prove  productive  of  enormous  value  to 
the  i)eo|)le  of  India  and  the  luiropeans  who,  jus  civilians  or  for  military  pur- 
poses, temporarily  or  ix-rmaiiently  reside  there.  Hut  the  same  conclusion 
applies  at  least  to  the  southern  portion  of  the  United  States.  .Vccordiiig 
to  Sir  Ronald  Ro.ss,  it  has  been  estimated  that  the  mean  animal  death  rate 
of  India  from  malaria  is  al)oul  ;5  per  1. ()()(),  and  that  the  ammal  actual 
mortality  is  about  1,1S(),()()().  Fevers  in  India,  as  oflicially  rei)orted, 
unfortunately  include  diseases  other  than  malaria,  and  the  true 
incidence  of  the  di.sejise  is,  therefore,  not  at  present  iuscertainable,  but 
there  is  the  most  conclusive  evidence  that  the  seriousness  of  the  problem 
has  been  intelligently  recogniz<Ml  by  the  Govermnent  and  the  people  of 
India,  as  illustrated  in  the  series  of  transactions  of  the  Coinmittee  for  the 
Study  of  Malaria  in  India,  edited  by  McKendrick  and  Christophers, 
which  include  some  exc<'editigly  valuable  notes  and  observations  on 
the  .sea.sonable  prevalence  of  ano|)helines,  with  special  reference  to  the 
potentialities  of  a  single  bn-rding-place.  and  the  mat hcinatics  and  epi- 
demiology of  malaria,  in  amplilication  of  the  ititcnvsting  cliapler  on  the 
measurement,  mortality  and  cost  of  malaria  in  the  treatise  by  Sir  Ronald 
Koss,*  which  involv<vs  considerations  also  ap[)licable  to  other  probjcnis 
of  prevental)le  diseases. 

•"The  Pr.vrnli.Mi  i.f  Miiluria."  Iiy  il.Miul.l  It..**.  Nrw  Y..rk.  11»I0.  Atlentioii  nwy  »lii.>  Ix-  .lirrrlr.1  hrr«  lu 
the  monuiiieiilul  lrc«li»c  on  iiiitlarin  by  Dr.  Vill.iri..  Awmli.  publLiheti  iiudor  iho  lille  "l^  M»i«ri». "  IViriuo, 
Italy.  1015. 

11 


.1  PLEA  FOR  ORGANIZED  ACTION 

Such  scientific  contributions  as  have  been  made  to  the  subject  of 
paludism,  through  the  transactions  of  the  Committee  for  the  Study  of 
Malaria  in  India,  emphasize  precisely  the  lesser  degree  of  scientific 
progress  which,  in  this  direction,  has  been  made  in  the  United  States 
regardless  of  the  truly  enormous  social  and  economic  interests  involved 
in  malaria  prevention,  at  least  in  the  Southern  States.  We  have  much 
to  learn  in  this  respect,  and  the  results  of  scientific  research  in  malaria 
and  related  problems  for  the  western  hemisphere  fall  far  short  of  the 
corresponding  attainments  in  the  eastern  hemisphere,  as  perhaps  best 
indicated  by  the  remarkable  results  achieved  by  the  Institute  for  Medi- 
cal Research  of  the  Federated  Malay  States,  which  in  1902  published  a 
monograph  on  "The  Malarial  Fevers  of  British  Malaya,"  by  Hamilton 
Wright,  subsequently  enlarged  upon  by  the  recently  issued  treatise 
on  "Rural  Sanitation  in  the  Tropics,"  by  Watson,  previously  referred 
to,  which  has  special  reference  to  the  antimalarial  work  in  Klang, 
Port  Swettenham,  and  elsewhere  in  the  Straits  Settlements,*  all  more 
or  less  in  conformity  to  the  control  of  malaria  in  Panama.  The  first  and 
fundamental  principle  of  such  an  effort  is  a  thoroughly  aroused  public 
understanding  of  the  importance  and  practical  possibilities  of  malaria 
eradication.  Such  conspicuous  illustrations  as  the  proceedings  of 
the  Imperial  Malkria  Conference,  held  at  Simla,  India,  1909,  the 
proceedings  of  the  Third  General  Malaria  Committee,  held  at  Madras, 
India,  1912,  the  report  on  an  investigation  into  the  causes  of  malaria 
in  Bombay  and  the  measures  necessary  for  its  control,  by  Bentley,  pub- 
lished in  Bombay,  1911,  and  the  two  equally  interesting  and  important 
reports  on  malaria  in  Bengal,  by  Maj.  A.  B.  Fry,  published  in  Calcutta, 
1912  and  1914,  are  sufiicientfor  the  present  purpose  of  emphasizing  the 
measures  and  means  which  have  been  adopted  in  other  countries  than 
ours,  even  though  the  question  here,  or  at  least  in  the  Southern  States,  is 
not  less  serious,  when  all  the  elements  of  the  problem  are  taken  into 
account,  than  in  the  tropical  portions  of  the  British  Empire.  Regarding 
no  other  problem  in  preventive  medicine  is  the  evidence  so  absolutely 
convincing.  Even  tuberculosis  can  not  show  anywhere  near  the  remark- 
able results  of  actual  reduction  and  gradual  elimination  which  have 
been  the  case  with  malaria  whenever  thoroughgoing  methods  and  means 
for  complete  eradication  have  been  adopted.  The  statistical  evidence 
in  support  of  this  contention  is  so  overwhelming  that  it  may  safely  be 


•In  the  Straits  Settlements,  according  to  the  annual  report  of  the  Medical  Department  for  1915,  by  Dr.  W. 
Gilmore  Ellis,  the  number  of  cases  of  malarial  fever  decreased  from  9,474  in  1912  to  5,590  in  1915.  The  number 
of  deaths  from  malaria  during  the  same  period  decreased  from  660  to  311.  The  data  are  limited  to  the  cases 
and  deaths  in  the  hospitals  of  the  colony.  In  the  Federated  Malay  States,  according  to  the  annual  report  •>( 
Dr.  Chas.  Lane  Sansom,  the  mortality  from  malaria  decreased  from  17,870  in  1912  to  15,208  in  1915.  The 
report  contains  an  interesting  account  of  antimalarial  measures  in  the  different  provinces  and  a  report  of  the 
Malaria  Advisory  Board  under  the  supervision  of  an  executive  engineer.  Appended  to  the  report  is  a  chart 
showing  the  true  malaria  death  rate  for  Kuala  Lumpur  Town  for  the  period  1907-1915.  During  the  first  year 
the  malaria  death  rate  was  9.7  per  1,000,  which  subsequently  to  1911  was  gradually  reduced  to  5.8  during  1912, 
to  4.2  during  1913,  to  3.9  during  1914  and  to  only  3.7  during  1915.  This  reduction,  achieved  through  anti- 
malarial measures,  was  obtained  at  an  aggregate  cost  of  $185,000,  for  the  entire  period,  largely  expended  on 
antimalaria  drainage  work. 

12 


A  PLEA  FOR  ORGAMZFJ)  ACTIOS 

asserted  that  it  is  primarily  a  question  of  general  intelligence  coordinated 
to  a  high  conception  of  public  duty,  without  which  the  desired  results 
are  not  obtainable. 

In  Jamaica  a  malaria  commission  was  appointed;  it  served  for  a  few 
years,  rendered  some  admirable  reports,  achieved  some  far-reaching 
practical  results,  but  was  permitted  to  terminate  because  of  govern- 
mental indifference  and  neglect.*  The  relatively  small  amount  of 
money  involved  in  antimalarial  measures  in  the  island  of  Jamaica 
could  have  been  saved  to  advantage  from  almost  any  other  item  of  public 
revenue,  with  the  practical  certainty  that  no  other  expenditure  would 
prove  productive  of  equally  far-reaching  social  and  economic  results  to 
the  population  concerned.  This  most  beautiful  island  of  the  West 
Indies  is  a  hundred  years  behind  in  the  achievement  of  its  most  obvious 
commercial  and  social  possil)ilities,  largely  l)ecause  of  the  extensive 
prevalence  of  malaria,  the  impaired  physique  of  the  natives,  the  impossi- 
bility of  profitable  cultivation  of  large  infected  areas,  and  the  com- 
plications resulting  from  malaria  in  the  increased  seriousness  of  many 
other  diseases.  But  in  this  respect  many  sections  of  our  Southern 
States  have  not  done  much  better,  and  as  yet  not  a  single  Southern  state 
has  gone  so  far  as  to  appoint  a  malaria  commission  or  official  state 
committee  for  the  purpose  of  making  even  a  preliminary  state  survey  for 
the  ascertainment  of  all  the  essential  facts  and  conditions  which  require 
to  be  known. 

Over  twenty  years  ago  William  Sydney  Thayer  and  John  Hewetson 
pu})lished  their  momimental  work  on  "The  Malarial  Fevers  of  Haiti- 
more."  That  work  itself  constitutes  one  of  the  most  useful  and  instruc- 
tive sources  of  information  regarding  the  malaria  prol)lem.  The  report 
was  subsequently  amplified  by  Dr.  Thayer  in  a  series  of  lectures  on 
malarial  fevers  (New  York,  1897),  including  a  concise  outline  of  the 
fundamental  i)rincii)les  of  malaria  pathology,  diagnosis,  prognosis 
and  trealmcnt.  Some  years  earlier  the  late  Dr.  George  M.  Sternberg 
published  his  work  on  "Malaria  and  Malarial  Diseases,"  which,  in 
a  more  comprehensive  manner,  |)rescnte<l  in  broad  outlines  the  con- 
ditions governing  the  development  and  dissemination  of  malaria,  with 
observations  on  the  spt'culalions  and  researches  relating  to  the 
nature  of  malaria  and  the  general  ellects  of  malaria,  all  of  which 
now  make  curious  and  interesting  reading,  since  it  was  not  until  185)8 
that  the  tru<'  cause  of  the  disease  was  discovered  by  the  ascertainment  of 
the  malarial  |)arasile  in  the  mos(|uilo  an<l  the  transmission  of  the  disease 
from  mos(|uitoes  to  man.  From  Sternberg  to  Thayer,  and  from  Thayer 
to  Craig  and  Deaderick,  we  have  not  been  wanting  in  (jualilied  medical 
research  fully  on  a  par  with  the  work  of  the  most  distinguished  medical 
authorities  of  other  countries.     Where  we  have  failed,  and  ((Uispicuously 

*Aniiiinl  l{r|M>rt!i  of  lli<-  Miiliiriji  (°c)Miiiii'<iii>ii  of  Jiiiiiaiin,  Drcriiilirr  ;J1,  lOIO.  iitui  for  Ihr  yrnr  rnJiii( 
Morrli.1l.  lOU.  KiiiK^ton,  Jniiini<n,  lOII-IUK. 

Sor,  niso.  Ili«-  AmiiiiiiI  U.|iort  of  llir  Sii|Mrinlrii(|i  iil  of  nrnlllinf  Jniiiiiira  for  tliryrnr  rii.linK  Mur.li  31.  I»I3, 
KinKslon,  Janinii'n,  11)1*1. 

l.i 


A  PLEA  FOR  ORGANIZED  ACTION 

so,  is  in  governmental  recognition  of  the  administrative  aspects  of 
malaria  prevention  and  control  and  the  absolute  hopelessness  of  any 
measurable  progress  in  the  direction  of  eradication  without  more  or  less 
drastic  governmental  interference.  Within  recent  years  some  very 
valuable  local  surveys  have  been  made  by  the  United  States  Public  Health 
Service,*  and  many  scientific  papers  and  reports  have  been  contributed  on 
important  technical  aspects  of  malaria  distribution,  prevention  and 
control,  but  the  efforts  of  the  service  in  this  direction  have  fallen  short 
of  the  required  permanent  results,  in  view  of  the  want  of  the  necessary  co- 
ordination of  municipal,  state  and  federal  efforts,  which,  for  their  success, 
require  exact  conformity  to  the  admirable  administrative  principles  de- 
veloped under  the  direction  of  Major-General  W.  C.  Gorgas  and  others  in 
Panama.  The  principles  of  mosquito  control  in  the  Panama  Canal  Zone 
and  the  actual  achievements  in  the  local  eradication  of  malaria  and 
yellow  fever  in  Cuba  and  Panama  have  been  set  forth  in  an  exceptionally 
lucid  and  convincing  manner  by  Joseph  A.  LePrince,  formerly  chief 
sanitary  inspector  of  the  Isthmian  Canal  Commission,  and  Dr.  A.  J. 
Orenstein,  assistant  chief  sanitary  inspector  of  the  Isthmian  Canal  Com- 
mission, in  a  work  issued  during  1916.  f  This  is  by  far  one  of  the  most 
notable  contributions  to  the  practical  study  of  the  problem  of  malaria 
eradication,  and  every  important  factor  of  the  problem  receives  adequate 
consideration  and  is  sustained  by  the  gratifying  results  of  actual  ex- 
perience. The  essentials  of  an  effective  antimalarial  campaign  at 
reasonable  cost,  largely  on  the  principle  of  intelligent  coordination  of 
governmental  and  other  efforts  and  activities,  more  or  less  in  conformity 
to  the  methods  found  practical  in  the  Panama  Canal  Zone,  are  briefly 
set  forth,  as  follows: 

J.  Meteorological  and  topographical  conditions:  these  are,  without 
question,  of  the  first  order  of  importance.  No  definite  conclusions  can 
be  arrived  at,  however,  without  a  preliminary  analysis  of  the  elementary 
meteorological  facts  concerning  a  given  community  and  the  precise  ascer- 
tainment of  the  essential  topographic  features,  by  means  of  topographic, 

*Among  the  more  important  of  the  recent  publications  of  the  United  States  Public  Health  Service  on 
malaria,  malaria  eradication,  etc.,  are  the  following:  No.  105,  Antimalarial  Measures  for  Farmhouses  and 
Plantations,  by  H.  R.  Carter,  191'2,  No.  108,  Malarial  Fevers:  Prevalence  and  Geographic  Distribution  in 
Alabama,  by  R.  H.  von  Ezdorf,  1913,  No.  159,  Malarial  Index  Work  Methods  Used  in  Obtaining  Blood,  Making 
Blood  Smears  and  Staining,  by  R.  H.  von  Ezdorf,  1914,  No.  160,  Malarial  Fevers:  Prevalence  and  Geographic 
Distribution  in  Arkansas,  by  R.  H.  von  Ezdorf ,  1914,  No.  172,  Malarial  Fevers:  Prevalence  and  Geographic 
Distribution  in  South  Carolina,  Georgia,  and  Florida,  by  R.  H.  von  Ezdorf,  1914,  No.  175,  Quinine  Prophylaxis 
for  Malaria,  by  H.  R.  Carter,  1914,  No.  186,  Malarial  Fevers:  Prevalence  and  Geographic  Distribution  in  Ala- 
bama, 1913,  by  R.  H.  vou  Ezdorf ,  1914,  No.  193,  Malarial  Fevers:  Prevalence  and  Geographic  Distribution  in 
Mississippi,  1913,  by  R.  H.  von  Ezdorf,  1914,  No.  217,  Mosquitoes  and  Malaria:  Report  on  a  Short  Trip  in 
Eastern  North  Carolina,  by  Chas.  Wardell  Stiles,  1914,  No.  244,  Impounded  Water:  Some  General  Considera- 
tions of  Its  Effect  on  the  Prevalence  of  Malaria,  by  H.  R.  Carter,  1915,  No.  257,  Impounded  Waters:  A  Study 
of  Such  Waters  on  the  Coosa  River  in  Shelby,  Chilton,  Talladega  and  Coosa  Counties,  Alabama,  to  Determine 
the  Extent  to  Which  They  Affect  the  Production  of  Anophelines,  and  of  the  Particular  Conditions  Which  In- 
crease or  Decrease  Their  Propagation,  by  J.  A.  LePrince,  1915,  No.  258,  Malaria  Control:  Drainage  as  an 
Antimalarial  Measure,  by  J.  A.  LePrince,  1915,  No.  272,  Anopheline  Surveys:  Methods  of  Conduct  and 
Relation  to  Antimalarial  Work,  by  R.  H.  von  Ezdorf,  1915,  No.  277,  Malaria  in  the  United  States:  Its  Preva- 
lence and  Geographic  Distribution,  by  R.  H.  von  Ezdorf,  1915,  No.  260,  Control  of  Malaria:  Oiling  as  an 
Antimosquito  Measure,  by  J.  A.  LePrince,  1915. 

t" Mosquito  Control  in  Panama,"  by  J.  A.  LePrince  and  A.  J.  Orenstein,  with  an  introduction  by  L.  O. 
HowRfd,  New  York.  1916. 

14 


A  PLEA  FOR  ORGAMZED  ACTION 

geological  and  soil  surveys.  As  yet  only  a  relatively  small  portion  of  the 
Southern  States  has  been  completely  surveyed  in  conformity  to  modern 
topographic  methods.  For  economic  reasons  it  has  seemed  best  to  the 
United  States  Geological  Survey  to  give  prior  consideration  to  western  and 
northern  states.  Every  community  is  individually  interested,  however,  in 
the  exact  ascertainment  of  local  topographic  features,  which  have  a  direct 
and  permanent  relation  to  the  mosquito  and  the  malaria  problems.  Of 
somewhat  lesser  importance  is  the  a.scertainment  of  surface  geologic 
features,  which  in  many  sections  of  the  South  have  been  mapped  by 
state  surveys  with  admirable  accuracy  and  completeness.*  This  con- 
clusion applies  particularly  to  the  surveys  which  have  been  made  of  the 
coastal  plains  of  Maryland,  Virginia,  North  Carolina  and  Georgia. 
Particularly  good  work  in  this  direction  has  also  been  done  by  the  State 
Geological  Survey  of  Florida.  Soil  surveys  are  of  great  practical  im- 
portance, and  it  is  most  fortunate  that  comjiaratively  rapid  progress  has 
been  made  in  this  direction  by  the  Bureau  of  Soils  of  the  United  States 
Department  of  Agriculture,  and  a  large  portion  of  the  Southern  States  has 
been  mapped  with  reasonable  completeness  and  attention  to  details. 
These  maps  are  of  sj)ecial  value  in  that  they  indicate  the  stream  margins, 
swami)S,  j)onds,  overfi(nved  land,  etc.,  which,  broadly  speaking,  are  the 
underlying  topographic  conditions  chiefly  responsible  for  the  local 
frequency  and  relative  intensity  of  malarial  diseases. 

No  thoroughgoing  analysis  has  been  made  of  meteorological  features, 
which  in  all  j>rol)ability,  however,  will  be  found  to  ha  of  secondary  im- 
portance. While  there  is  prol)aI)ly  a  fairly  constant  correlation  between 
rainfall  and  malaria,  nnich  depends  upon  topographic  features,  tem- 
perature, humidity  and  wind  direction,  aside  from  pro.ximity  to  the  sea. 
A  very  interesting  investigation  of  the  meteorology  of  malaria,  reported 
upon  in  considerable  detail  by  Matthew  D.  O'Connell  in  the  Journal 
oj  Tropical  Medicine,  emphasizes  the  urgency  of  an  analysis  in  com- 
plete detail  of  the  temperature  of  the  air,  the  drying  power  of  the  air 
and  the  hourly  Nclocily  of  the  wind,  and  their  possible  correlation  to 
malaria,  the  object  being  to  ascertain  the  atmospheric  conditions  which 
raise  the  body  temj)erature  to  a  condition  equivalent  U)  tiiermic  fever,  j 
The  view  heUl  by  Dr.  O'C'onnell  is  that  malaria  is  nut  eau.sed  by  mosquito 
transmission  or  malaria  parasites,  and  he  refers  to  the  relative  absence 
of  malarial  fevers  from  Fiigland  at  the  present  day  as  not  to  be  explained 
by  the  ])aueily  of  malarial  parasites,  since  they  an-  imported  in  abun- 
dance in  the  blood  of  soldiers,  sailors  and  otherswhoare  in\  alided  home  for 


•A  ulroiiK  n|>|M'al  for  iiidiirviiiriil  iiml  <iu|>|Mirt  in  lirlinlf  i>f  nil  rllorl  to  liriiii;  iil><)iit  llir  nirly  niniplrtioD  of 
the  t<i|)oKrB|ihir  iiiiip  of  lli<-  I'liili-.l  Slali-.s  luLt  l>r<ii  .hi-hI  duI  liy  n  CDimiiillcf  In  Kxp'-itilr  llin  ('oiiip|rti,>ii  of  thr 
Topot;r»pliir  Mnp  of  llic  I  iiiird  Slali-ii,  of  whirli  I'rof.  Willuun  V.  Dnvw.  K<'oloKi«t,  in  Ihc  r)iKiriiinn.  Tim  i« 
(iriHTvinK  of  Ihr  iiioiit  lirnrly  mipiiurt  on  t  li<-  part  of  all  who  arc  inlrrrgilnl  in  Ihr  ifirntific  and  rcunuiiiic  tolutian 
of  till-  prol>lrin  of  inalarin  rriidiiiilion. 

tAii  inslrmtivr  contriliulion  <in">onir  llnliilsuf  Malaria  not  C'onlrolM  l.y  the  MoMpiito"  w  •  '  '•  '-■I  m 
1901  hy  Dr.  Cliarlr*  Mirkii,  of  Diililin,  (in.,  illiiiilrati'il  liy  n  ninp  of  Lniirrnn  Connly,  wlilili  »ui{k*"  '" 

vnlur  of  lliuroiiKlily  upcriali/.oii  lo<al  malaria  ^lu<li«-<.     A  «oil  iiirvry  of  l.iiiirrn<>  <"oiinly  »«<  p.,  ',  i..- 

Kiirraii  of  Soil*  iu  lUlll, 

15 


A  PLEA  FOR  ORGANIZED  ACTION 

this  disease  from  countries  where  they  had  contracted  it.*  He  therefore 
holds  that  "The  absence  of  malarial  fevers  from  England  at  the  present 
time  can  hardly  be  due  to  any  scarcity  of  anopheles,"  and  he  concludes 
that  "it  seems  certain  that  malarial  fevers  have  disappeared  from  Eng- 
land without  the  employment  of  any  antimalarial  measures  except  the 
drainage  of  marsh  and  fen  land,  and  since  the  drainage  of  marsh  and  fen 
land  has  not  exterminated  anopheles  in  England,  it  is  difficult  to  under- 
stand what  caused  the  disappearance  if  they  are  spread  by  the  mos- 
quito." f  It  is,  therefore,  quite  clear  that  qualified  opinion  is  not  yet 
in  entire  agreement  even  regarding  the  causative  factor  in  malarial 
disease,  and  the  researches  of  Dr.  O'Connell  are  deserving  of  considera- 
tion as  suggestive  of  unrealized  possibilities  in  the  scientific  study  of 
meteoi'ology  in  relation  to  this  disease.  As  a  practical  question,  however, 
it  may  safely  be  said  that  thoroughgoing  antimalarial  measures,  in- 
volving the  destruction  of  breeding-places  of  anopheles  and  the  reduction 
of  the  same  to  relatively  unimportant  proportions,  have  invariably  been 
followed  by  the  eradication  or  substantial  reduction  of  the  disease.  | 

^.  The  species  of  anopheles  and  other  mosquitoes  in  the  area  affected  by 
malarial  disease:  It  is  not  merely  sufficient  to  ascertain  the  relative 
frequency  and  species  of  anopheles,  but  it  is  advisable  to  include  in  a 
thoroughgoing  scientific  survey  the  correct  ascertainment  of  all  the  local 
species  of  m.osquitoes,  whether  known  to  be  malaria-carrying  or  not.  The 
elaborate  investigations  of  the  mosquitoes  of  North  and  Central  America 
and  the  West  Indies  by  Howard,  Dyar  and  Knab  constitute  a  truly 
monumental  contribution  to  the  cause  of  ultimate  malaria  eradication, 
which  rests  fundamentally  upon  the  prior  ascertainment  of  the  species  and 
relative  frequency  of  mosquitoes  of  the  malaria-carrying  variety.  These 
researches  have  been  made  available  through  the  Carnegie  Institution  of 
Washington,  in  continuation  of  Dr.  Howard's  earlier  investigations  as 
chief  entomologist  of  the  United  States  Department  of  Agriculture. 
Mention  requires  to  be  made  in  this  connection  of  the  exceedingly  useful 
work  in  the  same  field  by  John  B.  Smith,  State  Entomologist  of  New 
Jersey,  published  as  a  report  of  the  New  Jersey  State  Agricultural 
Experiment  Station,  in  1904. S  The  report  includes  observations  in 
minute  detail  on  the  anatomy  of  mosquitoes,  the  habits  of  mosquitoes, 
the  processes  of  development  and  hibernation  and  finally  the  relation  of 
mosquitoes  to  disease,  and  practical  considerations  of  checks  and  reme- 
dies, including  the  natural  enemies  of  mosquitoes,  remedial  measures 

*The  subject  of  marsh  fevers  as  distinct,  from  ague  in  epidemic  form  is  described  by  Creighton  in  his  "History 
of  Epidemics  in  Great  Britain,"  who  also  deals  extensively  with  the  whole  subject  of  ague  and  its  prevalence 
in  early  times  throughout  England  and  Ireland. 

fThe  original  articles  by  Dr.  O'Connell  were  published  in  the  Journal  of  Tropical  Medicine,  London,  19H 
(Feb.  15,  June  15,  Aug.  15  and  Nov.  15),  1913  (June  2,  Sept.  1  and  Dec.  1),  1914  (Nov.  i),  1915  (May  1  and 
Aug.  2)  and  1916  (Mar.  15  and  Dec.  15). 

JFor  a  concise  but  comprehensive  account  of  the  practical  results  of  antimalarial  measures,  see  the 
articles  by  special  contributors  for  different  countries  of  the  world  included  in  the  treatise  by  Sir  Ronald  Ross 
on  the  "Prevention  of  Malaria,"  New  York,  1910. 

^Report  of  the  New  Jersey  State  Agricultural  Experiment  Station  upon  the  Mosquitoes  Occurring  within 
the  State,  Their  Habits,  Life  History,  etc.,  by  John  B.  Smith,  Sc.  D.,  Trenton,  1904. 

16 


A  PLEA  FOR  ORG  AM  ZED  ACTIOS 

in  general  and  destructive  measures,  as  well  as  observations  on  mos- 
quito campaigns.  In  the  same  field  of  practical  economic  entomology  a 
brief  reference  is  called  for  to  a  bulletin  on  mosquitoes,  by  the  Univer- 
sity of  the  State  of  New  York,  as  a  contribution  to  the  New  York  State 
Museum,  by  E.  P.  Felt,  state  entomologist,  including  observations  on 
the  distribution  and  abundance  of  mosquitoes,  the  migration  by  flight, 
the  methods  of  collecting  and  breeding,  the  haunts  and  breeding-places, 
natural  enemies  and  finally  methods  of  control.*  A  strictly  scientific 
mosquito  survey  is,  therefore,  of  the  first  importance  in  all  local  anti- 
malarial measures,  and  without  such  a  survey  such  measures  are  practi- 
cally certain  to  fail.  This,  of  course,  requires  the  aid  of  voluntary 
scientific  assistants  in  the  ascertainment  of  the  prevailing  species  of 
mosquitoes,  whether  malaria-carrying  or  not,  in  areas  subject  to  malaria, 
since  it  is  a  foregone  conclusion  that  intensive  investigations  of  this 
kind  can  not  be  carried  to  a  final  conclusion  by  paid  investigators  alone. 
The  most  practical  suggestions  with  reference  to  the  collection  of  mos- 
quitoes have  been  j)ul)lished  by  the  Museum  of  Natural  History,  of  the 
City  of  New  York,  but  unfortunately  the  publication  is  out  of  print. 

3.  Anopheles  'propagation  areas:  The  ascertainment  of  anopheles 
propagation  areas  is,  of  course,  another  essential  step  in  any  and 
every  mosquito-eradication  campaign.  The  breeding-places  being  known, 
the  methods  of  eradication  become  less  difficult.  It  is  absolutely 
necessary,  as  shown  in  the  experience  which  has  been  had  on  the 
Isthmus  of  Panama,  that  all  the  breeding-places  must  be  ascertained  in 
[)ractically  minute  detail.  This  means,  however,  that  the  area  to  be 
made  free  from  mosquitoes  may  be  of  rather  limited  extent,  since  any 
and  all  efforts  at  general  eradication  over  large  areas  are  certain  to  fall 
n)aterially  short  of  the  expected  results.  It  is  an  error  to  assume  that 
the  Panama  Canal  Zone  has  been  made  free  from  anopheles  mosquitoes. 
The  coticliisioti  api)li('s  only  to  the  iiihabilcd  area  and  a  relatively  small 
surrounding  section.  In  the  aggregate,  perhaps,  less  than  ten  per  cent,  of 
the  entire  Canal  Zone  has  been  brought  within  thoroughgoing  methods 
of  moscjuito  control  and  the  equivalent  malaria  eradication.  Obviously 
the  ascertainment  of  an()i)heles  propagation  areas  is  most  difficult  with- 
out the  aid  of  accurate  topograi)hic  and  soil  surveys.  In  any  event, 
such  efforts  are  materially  assisted  by  majjs  showing,  in  complete  detail, 
the  salient  topographic  and  .soil  features  of  the  region  under  considera- 
tion. The  elimination  of  anopheles  propagation  areius  is  frecjuently  a 
most  diflicwlt  and  often  an  expensive  matter,  but  jus  a  general  rule  a 
material  reduction  in  malaria-carrying  mos(initoes  by  means  t)f  the 
elimination  of  propagation  areas  can  be  secured  at  moderate  expense. 
The  essentials  of  such  elimination  arc  .set  forth  by  I/ePrince  and  Orcn- 
stein,  as  follows: 

(a)  Attacks  on  propagation  areas  l)y  filling. 

^Bulletin  No.  79  of  the  New  York  SUte  Muacum,  Albany,  1904,  "Ma«(|uitoPi  or  CiilioiJup  <rf  NVw  York 
SUte."  I.y  Eplirniin  Porlor  K.lt. 


A  PLEA  FOR  ORGANIZED  ACTION 

(b)  Attacks  on  propagation  areas  by  drainage. 

(c)  Attacks  on  propagation  areas  by  oiling. 

(d)  Attacks  on  propagation  areas  by  larvacides. 

(e)  Attacks  on  propagation  areas  and  adult  mosquitoes  by  natural 
enemies. 

(/)   Attacks  on  propagation  areas  by  clearing  bodies  of  water. 

(g)  Attacks  on  propagation  areas  by  removal  of  jungle. 

A  full  discussion  of  each  and  every  one  of  these  methods  of  attack  lies 
outside  the  plan  and  scope  of  this  plea.  It  is  self-evident,  however, 
that  each  and  every  method  is  governed  by  special  local  conditions, 
which  require  to  be  ascertained  by  means  of  strictly  scientific  surveys, 
including  considerations  of  both  malaria  frequency  and  mosquitoes  in 
their  relation  to  topographic  features,  meteorological  conditions  and 
artificial  circumstances,  such  as  impounded  waters,  which  have  been 
made  a  subject  of  special  consideration  in  a  report  of  the  United  States 
Public  Health  Service.  Each  method  of  attack  is  thoroughly  described 
in  the  work  of  LePrince  and  Orenstein,  and  amplified  by  details  of  act- 
ual experience  and  supplemented  by  statements  of  practical  results.* 

Most  of  the  methods  of  attack  on  anopheles  propagation  areas  involve 
superior  considerations  of  drainage  and  reclamation.  It  is,  therefore,  of 
the  first  importance  that  there  should  be  complete  and  hearty  coopera- 
tion between  all  local  efforts  at  malaria  eradication  and  the  plans  and 
purposes  of  drainage  commissions  and  other  public  bodies  of  an  engineer- 
ing character,  chiefly,  of  course,  such  as  have  to  do  with  the  building 
and  control  of  waterways,  levee-building,  hydroelectric  plants,  etc. 

4.  Screening  and  practical  destruction  of  adult  anopheles  in  houses: 
In  the  absence  of  measures  and  means  for  the  practical  elimination  of 
malaria-carrying  mosquitoes  as  an  essential  prerequisite  to  malaria 
eradication,  the  screening  of  houses  and  work-places  is  unquestionably  of 
very  considerable  value.  Unless  such  screening,  however,  is  complete,  it 
may  be  more  of  a  hindrance  than  a  help.  Only  the  best  kind  of  screens  is 
advisable  for  permanent  structures.  The  18-mesh  screen  is  recommended 
by  the  Panama  sanitary  authorities.!  Special  methods  are  urgently 
advised  in  the  case  of  railroad  construction  camps,  and  thoroughly  well- 
screened  cars  used  for  the  housing  of  laborers  should  be  insisted  on  by  the 
authorities.  As  observed  by  LePrince  and  Orenstein,  "The  crucial  point 
about  screening  is  the  thoroughness  with  which  the  work  is  done,  and  the 
constant  vigilance  and  care  that  must  be  exercised  in  speedily  detect- 
ing and  remedying  defects."  They  point  out,  however,  that  even  "a 
perfectly  screened  house  may  yet  offer  innumerable  avenues  for  the 
entry  of  mosquitoes,"  and  they  therefore,  by  inference,  suggest  the  prior 
importance  of  the  complete  destruction  of  anopheles  propagation  areas. 


*0n  the  relation  of  impounded  waters  to  the  prevalence  of  malaria,  two  publications  have  been  issued  by 
the  United  States  Public  Health  Service,  reprint  No.  244,  by  H.  R.  Carter,  and  reprint  No.  257,  by  J.  A. 
LePrince,  Washington,  1915. 

tThe  subject  of  screening  in  relation  to  the  practical  destruction  of  adult  anopheles  in  houses  is  fully 
described  in  Chapter  xv  of  LePrince  and  Orenstein's  work  on  "Mosquito  Control  in  Panama,"  1916. 

18 


A  PLEA  FOR  ORGANIZED  ACTIOS 

5.  On  the  possibilities  of  the  reduction  of  domestic  mosquitoes,  a  concise 
treatise  has  been  published  by  Edward  Halford  Ross,  for  the  purpose  of 
providing   instructions   for  the  use   of  municipalities,   tovm  councils, 
health  officers,  sanitary  inspectors  and  residents  in  warm  climates.* 
After  directing  attention  to  the  pathological  importance  of  domestic 
mosquitoes  and  restating  the  biological  considerations  of  mosquito  life 
and  propagation,  Ross  suggests  as  a  first  requirement  "a  fever  census," 
for  he  observes,  "unless  the  state  of  health  of  the  town  is  known  before 
the  sanitary  reform  is  begim  it  will  be  impossible  to  obtain  comparative 
statistics  and  there  will  be  no  means  of  showing  what  the  results  are." 
Following  the  fever  census,  a  further  requirement  is  an  approximate 
estimate  of  the  cost  of  mosquito  reduction  and  an  outline  of  the  ways 
and  means  to  be  followed.     The  financial  considerations  are,  of  course, 
of    the    first    importance    in    localities    where    extensive    engineering 
measures  may  be  required.     Accurate  statistics  of  previous  malaria 
frequency  are,  therefore,  necessary  in  support  of  the  plea  for  continu- 
ance of  municipal  or  state  expenditures  made  in  behalf  of  mosquito 
reduction  and  malaria  eradication.!     Ross  warns  against  unnecessary' 
extravagance,  and  he  properly  observes  that,  while  mosquito  reduction 
is  not  an  expensive  measure,  it  can  not  possiiily  be  done  for  nothing. 
The  cost,  of  course,  varies  widely  in  diflerent  localities,  and  no  general 
average  unit  of  cost  can  be  relied  upon.     The  entire  project  of  malaria 
eradication,  in  his  words,  rests  upon  the  fundamental  principle  "that  it 
is  the  duty  of  the  state  to  undertake  permanent  reforms  that  lead  to 
health."     Since  erroneous  conclusions  are  the  rule  rather  than  the  ex- 
ception, it  is  suggested  that  the  ascertainment  of  local  mosciuito  density 
be  made  during  the  period  of  maximum  density,  or  immediately  after 
heavy  summer  rains.     The  extent  of  the  water  surface  likely  to  be 
utilized  for  breeding  purposes  should  be  ascertained,  and  at  the  same 
time  the  number  of  garden  fountains,   water-butts,   cisterns,   ponds, 
garden  puddles  and  pools  should  be  counted  and  "the  presence  of  mos- 
quito larvae  or  pupae  in  them  ob.servcd"  should  be  written  down.     A 
house-to-house  examination  is  absolutely  essential,  and  without  such  an 
in.sj)Cction,and  reinspectioii  and  constant  supervision, the  sanitary  results 
of  the  Panama  Canal  Zone  administration  would  have  been  impossible. 
Granting,  in  the  words  of  Kdward  Ilallord  Ross,  that  "the  best  larva- 
cide  for  nios((uitoes  is  the  abolition  and  prevention  of  stagnant  water 
collection,"  it  is  a  foregone  conclusion  that  the  second  best  nu'tlio<l  is  the 
more  or  less  extensive  use  of  oil.  J     'J'he  technical  consideratioiLs  of  this 

*"Tbe  Krdurtion  of  Domntir  MoiK|iiitor«,"  by  Kclwnrd  Halforil  Hom,  I'liilatirlphia,  1911. 

tU<'fcrcncr  iiiny  nppropriati-ly  hr  inndi-  to  n  Hicknr.w  mirvcy  of  North  Caroliiiii  liy  Ihr  Ntrtropolilan  Liff 
Inxiirancc  Compitliy,  piil>luili<-fl  in  Ni-w  ^  <irk,  ll)ll>.  Tin-  rrmiltg  of  tliis  mirvcy  rnii  iiol  l><-  n-linl  ii|>oii  (or  thr 
prrxrnt  purposr,  in  that  thr  invrgliKntion  wiui  liiiiiir  iliiriiiK  thr  iiionlh  of  .\pril.  whrn  malaria  «.«  thr  ino«t 
important  di.iraac  in  thr  roait  roiinlirn  wuuhl  naturally  l»c  of  a  very  much  Iraarr  drgrw  of  frrqucqi-y  than 
diirinK  thr  nioiilhii  of  Au)(>iit  >nd  Srptrmhrr. 

Srr  in  thin  coniintioii  rrpriiil  <I7  of  thr  I'nitrd  Stale*  Pulilir  llralth  Srrvir-r  un  "Moaquilor*  anil  Malaria 
in  Kojilrrn  North  Ciirolirin,"  liy  Chnii.  \V.  Slilrs,  WiixhioKton,  ll>H. 

(Thr  Ki'iiTid  ipiriitioii  of  oiliiiu  nn  nn  nnliini><ii|iiito  mraxiirr  i*  diariiiard  by  i.  A.  I^Prinrr  in  rriirinl 
No.  tm  of  the  United  Stulm  riibjir  llralth  Srrvi<-r,  WoahinKlon,  IUI3. 

19 


A  PLEA  FOR  ORGANIZED  ACTION 

aspect  of  mosquito  eradication  are  much  more  complete  than  is  generally 
assumed  to  be  the  case,  and  failure  frequently  has  resulted  from  indiffer- 
ence to  fundamental  considerations.  Any  and  all  of  these  aspects  are  much 
more  involved  than  is  apparent  upon  supei'ficial  consideration,  and  in  its 
final  analysis  the  required  results,  if  they  are  to  be  permanent,  must  rest 
upon  a  thoroughly  well-considered  scientific  plan  of  local  health  adminis- 
tration and  sanitary  control.  Wherever  malaria  has  in  part  been  eradi- 
cated, as,  for  illustration,  in  certain  localities  of  the  Federated  Malay 
States,  on  the  Panama  Canal,  on  the  Suez  Canal  and  in  Kiiartoum,  the 
results  achieved  have  been  in  consequence  of  a  thoroughly  organized  local 
health  administration,  with  sufficient  powers  to  eliminate  the  risk  of 
flagrant  individual  violations  of  laws,  rules  and  regulations  intended 
solely  for  the  common  good.* 

Restating  the  conclusions  of  Edward  Halford  Ross,  the  plan  of  cam- 
paign for  the  reduction  of  domestic  mosquitoes  may  be  summed  up  in  the 
axiom,  which  he  suggests  should  be  published  broadcast :  No  stagnant  uiater. 
This  axiom,  when  applied  to  the  concrete  problem  of  mosquito  eradica- 
tion, is,  however,  often  an  almost  insuperable  initial  obstacle.  The 
exact  ascertainment  of  all  places  where  stagnant  water  exists,  including 
holes  in  trees,  railway  ditches,  ornamental  ponds,  large  and  small  water- 
tanks,  bilgewater  on  barges,  etc.,  involves  many  practical  difficulties. 
As  observed  by  Ross,  "Thousands  of  mosquitoes  may  be  produced  from 
a  single  saucer  of  water  within  three  weeks,  and  neglect,  therefore,  in 
matters  of  small  detail  may  be  followed  by  lamentable  consequences." 
As  shown,  however,  in  Panama  and  elsewhere,  the  practical  eradication 
of  malaria  is  attainable  at  reasonable  expense,  and  certainly  so  under  the 
less  than  semi-tropical  conditions  common  to  most  of  the  Southern  States. 
In  strictly  tropical  countries,  with  a  very  heavy  rainfall  and  a  very  high 
average  range  of  temperature  and  humidity,  the  difficulties,  of  course, 
are  more  serious.  Even,  however,  under  the  most  trying  conditions  of 
extreme  tropical  life,  results  have  been  achieved  which  would  have 
been  considered  absolutely  impossible  even  a  few  years  ago.  Mosquito 
and  malaria  eradication  efforts  have  occasionally  failed,  and  even  dis- 
astrously so  in  some  conspicuous  instances,  but  the  general  principles  \ 
of  radical  measures  are  now  so  thoroughly  understood  that  there  is  no 
more  reason  for  the  endemic  continuance  of  malaria  than  for  that  of 
yellow  fever,  typhoid  fever,  cholera  or  plague,  f 

6.  The  most  modern  conceptions  of  malaria  and  the  transmission  of 
dfsease  were  restated  by  Sir  Ronald  Ross,  in  his  Huxley  Lecture  of  1914, 
reprinted  in  the  Scientific  American  Supplement  for  January  23,  1915. 
After  considering  that  it  was  only  in   1880  that   Laveran  made  the 

•Permanent  progress  in  malaria  eradication  depends,  of  course,  in  a  large  measure,  upon  sanitary  progress 
in  general.  The  close  relation  of  sanitary  problems  to  many  other  medical  problems  is  best  illustrated  in  the 
admiralile  report,  by  Prof.  W.J.  Simpson,  on  Sanitary  Matters  in  Various  West  African  Colonies,  published  as 
Parliamentary  paper  Cd.  4718,  London,  1909.  The  results  of  effective  sanitary  measures  are  brought  out  in 
the  vital  statistics  of  non-native  officials  serving  in  British  West  African  colonies.  The  returns  for  1914  were 
issued  as  a  Parliamentary  paper,  Cd.  7871,  London,  1915. 

tSee  "Sanitation  in  Panama,"  by  Wm.  C.  Gorgas,  I\L  D.,  New  York.  1915. 

20 


A  PLEA  FOR  ORGAMZKD  AiTIOX 

important  discovery  that  malaria  was  invariably  associated  with  a  minute 
protozoal  parasite  of  the  blood,  it  is  not  discouraging  that  a  larger  meas- 
ure of  progress  in  malaria  eradication  should  not  have  been  achieved 
during  so  comparatively  short  a  period  of  time,  considering  the  extensive 
prevalence  of  the  disease  throughout  the  ages  of  the  entire  historic 
period.  Sir  Ronald  Ross  properly  refers  to  malaria  as  certainly  the 
most  important  disease  in  the  tropics,  and  perhajjs  in  the  world.  Even 
500  years  B.  C,  he  points  out,  the  ancients  were  acquainted  with  the  fun- 
damental law  of  malaria — that  is,  its  connection  with  stagnant  water  such 
as  marshes,  etc.,  but  even  at  the  present  time  the  population  generally  is 
indifierent  to  stagnant  water  and  promiscuously  j)ermits  the  continuance 
of  breeding-places  in  localities  and  sections  where  it  is  perfectly  obvious 
that,  l)ecause  of  such  neglect  and  indifference,  malarial  disease  is  the 
causative  factor,  directly  or  indirectly,  of  most  of  the  ill-health  afflicting 
the  community.  Ross  commenced  his  malaria  investigations  on  the 
theory  of  mosquito  transmission  at  the  suggestion  of  Sir  Patrick  Man- 
son  in  1896-1897,  and  in  1897  he  finally  correctly  ascertained  the  true 
causative  factor  in  the  disease.  The  discovery  itself  did  not  become 
common  knowledge  until  about  1898,  so  it  is  practically  only  about 
eighteen  years  that  the  mosquito  transmission  of  malaria  has  been  gen- 
erally accepted  and  generally  understood.*  Once  that  the  principle  was 
clearly  established,  the  conclusion,  as  summarized  by  Sir  Ronald  Ross, 
became  entitled  to  unconditional  acceptance:  "We  now  have  a  great 
sanitary  ideal  put  before  us — so  to  manage  our  habitations,  villages, 
towns,  and  cities  that  the  vermin  in  them  shall  be  reduced  to  the  lowest 
po.ssible  figures.  Scores  of  entomologists  and  medical  men  are  now 
dealing  exactly  witii  tiie  habits  of  these  creatures  and  showing  us  how  to 
effect  the  rcfpiired  object.  It  demands  only  intelligence,  energy,  and 
organization  on  the  part  of  administrators.  Unfortunately  these  quali- 
ties are  not  always  forthcoming,  and  administration  often  lags  years 
behind  the  dictates  of  science." f  Regardless  of  all  that  is  known  con- 
cerning malaria  transmission  through  the  moscjuito  au<l  the  al)solute 
urgency  of  effective  measures  of  eradication  and  control,  Sir  Ronald  Ross 
is  unhappily  justified  in  his  final  conclusion  that  "Although  fifteen  years 
have  elapsed  since  many  of  the  facts  which  I  have  described  were  dis- 
covered, I  think  that  I  may  say  after  constant  study  of  the  subject,  and 
with  all  due  consideration,  that    iiianhirul  h(t.s  liillirrto  not  effected  more 

•An  rxccptionnlly  sufCRrstivr  illustmlion  of  W\v  most  cfTocUvc  diMcminnliun  of  I  rust  worthy  information  on 
malnrin  w  to  be  found  in  nn  o\itlino  of  I.-hh  tlinn  two  pnK«'»  in  the  "First  (ourM-  in  Cirnrrnl  Srirncr."  hy  F.  D. 
Bnrlxr  iind  otli.r!i.  Hniry  Molt  &  Co.,  Ntw  York.  lltKl.  The  most  convenient  Keiierul  .li»rn.«ion  of  mulitria  for 
Iny  readers  is  Fiirmeri'  Hiiilitin  t.'.O,  isHiie<l  l.y  the  Inited  Stnles  Depiirtment  of  Aitrieultiire.  for  Rrntuitous 
.liHtril.iilion.  entitled  "Some  Fa.  Is  Al.oul  Maiiiria."  l>y  I..  O.  Howard.  I'h.  D..  Wnsl.iiiKlon.  lOKl. 

tThn  following  lire  the  most  iiseful^sourees  of  modern  knowh-<lK'e  re^ardinK  niahirin  with  sperinl  reference 
1(1  tropical  countries:  "The  Diseas.-s  of  Warm  Countries."  l.y  H.  Schenhe,  Ixindon,  ll)0.i,  ".Manual  of  Tropical 
M.-.licine."l,y(nslell»niaii.i(lialniers,  <dj;d..  .New  York.  10I.S.  "Tropical  Diseoses.a  Manual  of  the  Dineuesof 
Warm  Countries,"  I. V  Sir  I'alri.k  Maiison.  5tli  K.I. ,  New  York.  lIMi.  "Tropi.al  llyifienefor  Resi.lenis  inTropi.  ..I 
nn.l  Sul.-Tropi.al  Countries,"  l.y  Sir  I'ard.-y  Lukis.  .1.1  F..I..  (  al.ulta  an.l  U,n.loii.  HMS.  "Health  I'reservation 
in  West  Africa."  I.v  J.  (has.  Uvan.  I^m.lon.  lUl  I.  "The  I'rinciplc,  of  HyKiene  as  Appli'd  to  In.pical  an.l  >ub- 
Tropical  Climntn."  Ijy  W.  J.  i{.  .^imp.on.  Loudon.  lOOH,  and  the  article  "Molaria. "  l.y  U.  H.  von  Ei.lorf.  lo 
II  Hrferene«-  Handbook  of  the  Mrdiral  Scicncri.  Vol.  vi.  New  York.  1010. 

^1 


A  PLEA  FOR  ORGANIZED  ACTION 

than  about  one-tenth  of  the  improvement  of  health  ivhich  it  might  have 
effected  already  if  it  had  put  its  heart  into  the  business." 

This  is  precisely  the  problem  as  it  concerns  the  United  States  and,  in  fact, 
the  entire  western  hemisphere,  wherever  the  incidence  of  malaria  is  of  meas- 
urable proportions  at  the  present  time.  As  observed  by  Major-General 
Gorgas,  in  his  address  on  the  sanitary  organization  of  the  Isthmian 
Canal  as  it  bears  upon  antimalarial  work,  "though  there  has  been  muc? 
antimalarial  prophylaxis  in  the  United  States  since  anopheles  have  beer, 
demonstrated  to  be  the  carriers  of  the  plasmodium,  this  disease  is  yet  far 
from  being  eliminated,  especially  in  the  South,"  and  he  states  with 
reference  to  malaria  eradication  that  "lack  of  success  in  any  com- 
munity must  mean  that  the  rnodus  operandi  has  been  inadequate 
and  imperfect,  the  fault  generally  being  that  details  have  been  neglected 
or  ridiculed  as  too  trivial  for  attention."  As  well  said  in  the  Scientific 
American  of  December  7,  1912,  with  reference  to  the  address  of  Dr. 
Gorgas,  "When  malaria  can  be  practically  extinguished  in  such  a  region 
as  the  Panama  Canal  Zone,*  the  same  thing  can  be  done  practically 
anywhere  else," and Gorgas's  fundamental  principles,  in  the  order  of  their 
importance,  are  enumerated  as  "(1)  the  habitat  of  anopheles  during  the 
larval  stage  is  destroyed  within  a  hundred  yards  of  dwellings,  since  the 
larvae  of  this  mosquito  live  only  in  clear,  fresh  water,  which  is  plentifully 
supplied  with  grass  and  algae;  (2)  all  protection  for  the  adult  mosquito 
must  be  destroyed,  since  the  adult  is  weak  on  the  wing,  not  generally 
flying  far  and  needing  plenty  of  grass  and  brush  for  protection  against 
the  wind;t  (3)  all  habitations  are  screened,  but  effectively,  for  screens  as 
ordinarily  put  up  without  expert  supervision  are  of  little  use;  (4)  when 
breeding-places  can  not  be  destroyed  by  drainage,  the  larvae  must  be 
destroyed  by  means  of  crude  petroleum,  or  some  other  larvacide." 
These  are  principles  not  difficult  of  application,  but  they  require  an 
active  interest  on  the  part  of  the  community  in  clear  realization  of  the 
fundamental  concept  that  the  health  of  the  nation  is  the  wealth  of  the 
nation,  and  that  health  squandered  ruthlessly  and  recklessly  is  even 

*The  following  table  will  show  in  an  abbreviated  form  the  very  material  reduction  in  the  malaria  mor- 
bidity and  mortality  rate  among  Isthmian  Canal  Zone  employees  during  the  period  of  American  construction. 
The  rates  are  subject  to  the  qualification  that  they  are  based  on  the  number  of  names  on  the  payroll  and  not 
on  the  true  average  number  of  persons  employed. 

Deaths  from  Malaria  Hospital  Cabks  of  Malaria 

Average  Number  Rate  per  Rate  per 

Year  of  Employees  Number        10,000  Employees  Number  100  Employees 

1906 26,547  233  87.8  21,739  81.9 

1907 39,343  154  39. 1  16,753  42. 6 

1908 43,890  73  16. 6  12,372  28. 2 

1909 47,167  52  11.0  10,169  21.6 

1910 50,802  50  9.8  9,487  18.7 

1911 48,876  47  9.6  8,987  18.4 

1912 50,893  20  3.9  ,              5,623  11.0 

1913 56,654  21  3.7  4,284                  7.6 

1914 44,329  7  1.6  2,886                  6.6 

1916 34,785  9  2.6  1,570                  4.5 

1916 33,176  3  0.9  493                    1.5 

fThe  malaria  morbidity  and  meteorological  statistics  of  the  Panama  Canal  Zone  with  special  reference 

to  wind  force  indicate  a  pronounced  negative  correlation  and  apparently  prove  that  the  rate  of  incidence  rises 

or  falls  in  inverse  proportion  to  wind  force. 

22 


A  PLEA  FOR  ORGANIZED  ACTION 

worse  than  the  unpardonable  waste  of  natural  resources  and  accumu- 
lated material  possessions.  As  pointed  out  in  an  editorial  of  the  Journal 
of  the  American  Medical  Association  on  malaria  and  the  development 
of  the  South,  after  directing  attention  to  the  measures  and  means 
adopted  for  the  possible  control  of  hookworm  and  pellagra,  "Recent 
agitation  and  information  concerning  these  two  diseases  have  placed 
them  in  the  limelight  almost  to  the  exclusion  of  the  older  and  better 
known  disease,  malaria,  which  is  still  a  tremendous  menace  and  handicap 
to  industrial  progress."  Attention  is  also  directed  to  the  interest  in  the 
subject  on  the  part  of  the  Southern  Medical  Association,  as  shown  by  the 
appointment  of  a  special  commission,  of  which  Capt.  Charles  F.  Craig, 
of  the  Army  Medical  School,  was  made  the  chairman,  and  which, 
among  its  membership,  included  Dr.  C.  C.  Bass,  the  discoverer  of  the 
method  of  cultivating  the  malarial  plasmodium.*  In  concluding  the 
editorial,  it  was  said  that  the  work  of  this  commission,  which  originated 
wholly  within  the  medical  profession,  should  be  of  inestimable  benefit  to 
the  South,  and  that  it  should  be  encouraged  and  supported  by  the  local 
and  national  governments  until  malaria  in  the  South  had  been  as  com- 
pletely exterminated  as  yellow  fever.  This,  it  was  held,  was  possible,  but 
a  much  greater  and  more  expensive  task  than  the  eradication  of  the 
former  disease,  and  the  burden  of  it  should,  therefore,  be  borne  by  the 
whole  people.  The  w^ork  of  the  commission  was  tentative  and  incon- 
clusive, because  the  necessary  support,  financial  and  otherwise,  was 
not  forthcoming,  nor  was  the  required  governmental  cooperation, 
whether  federal,  state  or  municipal,  secured  to  the  degree  essential  to 
the  attainment  of  substantial  results. 

The  daion  of  a  new  era:  It  was  in  profound  appreciation  of  these 
facts  that  a  new  plan  of  procedure  seemed  advisable,  and  in  fact  neces- 
sary, for  the  purpose  of  carrying  into  effect  the  following  important 
resolution  unanimously  adopted  by  the  Second  Pan-American  Scientific 
Congress : 

The  Second  Pan-American  Scientific  Conerress,  recognizing  tliat  the  educa- 
tion of  the  public  in  the  elementary  facts  of  malaria  is  of  the  utmost  importance, 
requests  that — 

The  American  Republics  inaugurate  a  well-considered  plan  of  malaria  eradi- 
cation based  upon  the  recognition  of  the  principle  that  the  disease  is  prevent- 
able to  a  much  larger  degree  tlian  has  thus  far  been  achieved. 

It  is  said  in  the  official  text,  in  explanation  of  the  resolution,  that  it 

was  pointed  out,  in  the  discussions  of  the  section  on  Public  Health  and 

Medical  Science,  that  "in  semi-tropical  and  tropical  regions  of  the  western 

hemisphere  the  supreme  importance  of  malaria  as  a  problem  of  public 

health    was   recognized    })y    all    governmental,    medical,    and   sanitary 

authorities,"  and  that  "it  was  stated  l)y  competent  authorities  that  the 

economic  loss  due  to  the  prevalence  of  malaria  could  be  overcome  by 

diminishing  the  mortality;    that  the  loss  occasioned  by  mortality  due 

to  malarial  fever  wius  one  of  the  most  serious  evils  affecling  the  health 

*A  <on<iso  prcscnlnlion  of  tlir  K<'iii-ral  iiiiilnrin  prul>li'ni  liy  Cliiia.  C  Hiis.s  wn.s  coiilrilnilril  to  the  Com - 
mfmornlion  Voliiim-  of  tlic  AiinTicati  Mnliciil  Amiociutioii,  CliicnKo,  1915. 

is 


A  PLEA  FOR  ORGANIZED  ACTION 

and  happiness  of  the  people,  and  that  the  problem  [of  malaria  eradica- 
tion] in  all  its  aspects  had  not  yet  received  the  amount  of  public  interest 
and  scientific  investigation  commensurate  with  its  world-wide  im- 
portance."* This  resolution,  unanimously  adopted  by  one  of  the  most 
important  international  gatherings  ever  held  in  the  United  States  in  be- 
half of  the  furtherance  of  the  cause  of  more  amicable  relations  between  the 
American  Republics  marks  a  milestone  in  human  progress,  for  it  is 
inconceivable  that  the  nations  which  have  pledged  themselves  to  this  rule 
of  action  will  ever  prove  neglectful  of  or  indifferent  to  the  principle  thus 
enunciated  and  the  practical  solution  thus  proposed,  for  the  ultimate  bet- 
terment of  living  conditions  throughout  a  vast  portion  of  the  western 
world.  All  the  fundamental  elements  of  malaria  eradication  are  now 
thoroughly  understood  and  they  require  only  to  be  made  public  property 
in  the  broadest  possible  sense.  The  apathy  of  governments  and  of 
communities  require  to  be  shattered  by  an  appeal  to  the  conscience,  the 
intelligence,  the  self-interest  of  the  people  concerned.  The  elementary 
facts  of  the  disease  are  readily  within  the  comprehension  of  even  persons  of 
less  than  average  intelligence,  and  they  can  be  brought  within  the  public 
understanding,  even  on  the  part  of  school-children,  as  best  illustrated  by 
the  admirable  manual  published  by  the  Philippine  Board  of  Health,  f  A 
common-sense  descriptive  account  of  the  transmission  of  the  disease  by 
malaria-carrying  anopheles  should  be  made  available  as  a  part  of  the 
curriculum  of  every  public  school  in  the  Southern  States,  and  every 
child  should  have  accurate  knowledge  of  the  local  species  of  disease-carry- 
ing mosquitoes  most  detrimental  to  health  and  life.t  Aside  from  the  intel- 
lectual interest  thus  aroused  in  the  study  of  natural  phenomena,  the 
child  gradually  would  acquire  an  active  and  wholesome  interest  in  the 
broader  questions  of  public  health  and  sanitary  science,  for  it  is  these 
that  will  form  the  cornerstone  of  a  better  national  life  than  we  have 
heretofore  known,  and  through  these  that  countless  years  of  life  will 
be  saved  to  the  community,  to  the  enormous  social  and  economic  ad- 
vantage of  all  concerned.  Measurable  human  progress  consists  not 
only  in  the  accumulation  of  material  wealth,  however  vast,  in  inven- 
tions, however  marvelous,  or  intellectual  attainments,  however  aston- 
ishing, but  as  much,  if  not  more,  in  the  lengthening  of  human  life, 
in  the  elimination  of  needless  disease,  in  the  prevention  of  useless 
accidents  and  in  the  consequential  increase  in  real  human  happiness, 
obtained  through  the  realization  of  a  distinctly  higher  level  of  genuine 
civilization.  § 

*"The  Final  Act  and  Interpretative  Commentary  Thereon,"  Second  Pan-American  Scientific  Congress, 
by  James  Brown  Scott,  LL.  D.,  Washington,  Government  Printing  Office,  1916,  p.  129  et  seq. 

tSee  "Sanitary  Inspectors'  Handbook,"  by  Carroll  Fox,  M.  D.,  Government  of  the  Philippine  Islands,  De- 
partment of  the  Interior,  Bureau  of  Health,  Manila,  1913,  pp.  64-67,  149,  163-164. 

f'Malaria,  Lessons  on  Its  Cause,  Prevention,"  etc.,  for  use  in  schools,  by  H.  R.  Carter,  United  States  Public 
Health  Service,  Supplement  No.  18  to  the  Public  Health  Reports,  July  17,  1914,  3d  Ed.,  Washington,  1916. 

^Considerable  information  of  practical  value  in  the  study  of  the  economic  importance  of  preventive 
medicine  will  be  found  in  my  address  on  "The  Significance  of  a  Declining  Death  Rate,"  Transactions  First 
National  Conference  on  Race  Betterment,  Battle  Creek.  Mich.,  1915. 

24 


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PART  II 


A  PLAN  FOR  ORGAxNIZED  PREVENTION  AND  CONTROL 

A  well-considered  working  plan  for  the  gradual  eradication  of 
malarial  diseases  throughout  the  western  henn'sphere  must  necessarily 
be  the  result  of  an  exceptionally  qualified,  active  and  continued  interest 
on  the  part  of  each  and  every  member  of  the  National  Committee. 
The  following  tentative  plan,  worked  out  in  some  detail,  with  a  due 
consideration  of  all  the  interests  and  activities  more  or  less  directly 
concerned,  may  be  found  useful  in  the  ultimate  perfection  of  the  final 
program  of  the  National  Committee  in  the  direction  of  a  broadening 
of  the  original  plan  and  scope  of  the  Committee's  work  as  agreed  upon  at 
a  meeting  held  in  the  office  of  the  Surgeon-General  of  the  United  States 
Public  Health  Service  at  Washington  on  May  10,  191G.  The  charter 
membership  of  the  Committee  is  as  follows: 

I.     Membership  of  the  National  Committee  on  Malaria 

Dr.  C.  (/.  Bass,  Medir^al  D<'j)art incut,  Tulane  University  of  Louisiana,  New 
Orleans,  La.  (Scientific  Director  of  tho  cxfX'rimental  malaria  eradication  work  in 
Mississippi  of  the  International  Health  Commission.) 

Dr.  Rupert  Blue,  Surtieon-CJeneral,  United  States  Public  Health  Service, 
Washington,  D.  C. 

Dr.  W.  E.  Britten,  State  Entomoloe:ist,  Connecticut  Agricultural  Experiment 
Station,  New  Haven,  Conn. 

Dr.  H.  R.  Carter,  United  States  Puiilic  Health  Service,  United  States  Marine 
Hospital,  Baltimore,  Md. 

Capt.  Chas.  F.  Craig,  M.  D.,  Medical  Corps,  United  States  .\rmy.  Fort 
Leavenworth,  Kans.  (Late  memln'r  of  thi-  United  States  Army  hoard  for  tho 
study  of  tropical  fliseases  in  the  IMiilip|)iiH;s  urid  author  of  ".Malarial  Ft-vers," 
New  York,   liKJO.) 

Dr.  Wni.  H.  Deaderifk,  Hot  Springs,  .\rl<.  (.Joint  author,  with  Lloyd  Thomp- 
son, M.  D.,  of  "Eiuiemic  Disea.ses  of  the  Southern  States,"  Philadelphia,  lOH).) 

Dr.  W.  K.  Decks,  (Jeneral  Medical  Superintendent,  United  Fruit  Company, 
New  '^'ork  City.  (F^ormerly  Chief  of  the  Medical  Clinic,  Ancon  Hospital, 
Panama  ( "anal  Zone.) 

Dr.  Oscar  Dowling,  President  of  lh<'  liouisiana  State  Board  of  Health,  Now 
Orleans,  La. 

Major-Oeneral  W.  C.  Clorgas,  United  States  Army,  Wasljington,  D.  C. 

Dr.  Frederit'k  R.  Oreen,  Si^cretary  oflhe  Ccmncil  <ni  Healthand  Pulilic  Instruc- 
tion, .\meriean  .Medical  .Association,  Chicago,  III. 

Dr.  .Scale  Harris.  Editor  of  the  Soul/urn  Mniintl  Journal,  Hirtninghani,  .\la. 
Dr.  Thomas  .1.  Ileadlee,  ,Sl;ile  Entomologist.  N«'w  Brunswii'k,  N.  J. 

Dr.  (Iraham  K.  Henson.  .State  Boanl  of  lleallh,  .Faeksonville.  Fla.  (.Viithor 
i)f   "Malaria,    Etiology,   Pathology,   Diagnosis,    Prophylaxis,"   St.  I^ouis.  IDI.J.) 

«7 


A  FLAX  FOR  ORGAMZFD  FRFAEXTIOX 

Frederick  L.  Hoffman,  LL.  D.,  Statistician  The  Prudential  Insurance  Com 
pany  of  America,  Newark,  N.  J. 

L.  O.  Howard,  LL.  D.,  Chief  of  Bureau  of  Entomology,  United  States  Depart- 
ment of  Agriculture,  Washington,  D.  C. 

Mr.  Arthur  Hunter,  Actuary  The  New  York  Life  Insurance  Company, 
New  York  Cit3\     (President  Actuarial  Society  of  America.) 

Dr.  W.  D.  Hunter,  Bureau  of  Entomology,  United  States  Department  of 
Agriculture,  Washington,  D.  C. 

Dr.  J.  W.  Kerr,  Assistant  Surgeon-General,  United  States  Public  Health 
Service,  Washington,  D.  C. 

Dr.  W.  S.  Leathers.  Director  of  Public  Health,  Jackson,  Miss.  (Administra- 
tive Director  in  charge  of  the  malai'ial  eradication  work  in  Mississippi  of  the 
International  Health  Commission.) 

Mr.  Joseph  A.  LePrinee,  C.  E.,  A.  M.,  United  States  Public  Health  Service, 
New  Orleans,  La.  (Late  Chief  Sanitary  Inspector,  Isthmian  Canal  Commis- 
sion, and  author  of  "Mosquito  Control  in  Panama,"  New  York,  1916.) 

Dr.  Charles  F.  ISIason,  Medical  Corps,  United  States  Army.  (Late  Chief 
Health  Officer,  Panama  Canal  Zone.) 

Dr.  J.  Y.  Porter,  State  Health  Officer,  Jacksonville,  Fla. 

Dr.  W.  S.  Rankin,  State  Health  Officer,  Raleigh,  N.  C. 

Dr.  M.  J.  Rosenau,  Harvard  Medical  School,  Boston,  Mass.  (Author  of 
"Preventive  Medicine,"  New  York,  1913.) 

Dr.  E.  R.  Stitt,  Medical  Inspector,  United  States  Navy,  Washington,  D.  C. 

Dr.  John  M.  Swan,  Rochester,  N.  Y.  (Secretary  American  Society  for  Tropi- 
cal Medicine.) 

Dr.  W.  S.  Thayer,  Baltimore,  Md.  (Joint  author,  with  John  Hewetson, 
M.  D.,  of  "The  Malarial  Fevers  of  Baltimore,"  Johns  Hopkins  Hospital  Reports, 
1895,  and  author  of  "Lectures  on  the  Malarial  Fevers,"  New  York,  1897.) 

R.  H.  von  Ezdorf,  Surgeon,  United  States  PubUc  Health  Service,  New  Orleans, 
La.     (Since  deceased.) 

Dr.  Robert  Wilson,  Jr.,  President  of  the  South  Carolina  State  Board  of 
Health,  Charleston,  S.  C.     (Late  President  of  the  Southern  Medical  Association.) 

II.     General  Plan  of  Organization 

The  administrative  direction  of  the  work  of  the  Committee  is  to  be  in 
charge  of  an  Executive  Committee,  consisting  of  an  Honorary  Chair- 
man, an  Active  Chairman,  a  Secretary  and  the  Chairmen  of  the 
Subcommittees,  a  majority  of  whom  shall  constitute  a  quorum. 

It  is  recommended,  but  at  present  not  provided  for,  that  state  com- 
mittees be  formed  in  each  and  every  state  in  which  malaria  exists  as  a 
serious  public-health  problem. 

The  general  objects,  plans  and  purposes,  and  the  organization  of  the 
National  Committee,  in  detail,  as  agreed  upon  at  the  Washington 
meeting  on  May  10,  1916,  are  as  follows: 

Objects  of  the  Committee.  The  plan  and  scope  of  the  Committee  shall  be : 
(a)  To  stimulate  the  scientific  and  public  interest  in  malaria  problems. 
{h)  To  serve  as  a  medium  through  which  societies  and  individuals 

may  become  identified  with  the  study  and  prevention  of  malarial 

diseases. 


A  PLAX  FOR  ORG  AM  ZED  PRFA'EXTfOX 

(r)   To  coordinate  the  efforts  of  these  agencies  with  those  of  consti- 
tuted federal,  state  and  local  authorities. 

Character  of  the  Organization.  The  Committee  shall  be  a  voluntary 
organization,  its  members  shall  ser^'e  without  compensation,  and  there 
shall  be  no  membership  dues. 

Membership.  Persons  who  have  accepted  membership  (at  the  time  of 
organization)  shall  be  known  as  charter  members. 

The  executive  officers  of  the  state  boards  of  health  of  states  in  which 
malaria  exists  as  a  serious  public-health  problem  and  state  officers 
charged  with  the  enforcement  of  laws  for  the  suppression  of  disease- 
bearing  mosquitoes  are  invited  to  become  members  of  the  Committee. 
Others  interested  in  the  objects  of  the  Committee  may  from  time  to  time 
become  members  by  vote  of  the  Committee. 

Meetings.  There  shall  be  a  meeting  of  the  Committee  held  once 
annually  at  the  call  of  the  Chairman  at  such  time  and  place  as  he  may 
deem  most  suitable.  Special  meetings  may  be  had,  however,  on  the 
call  of  the  Chairman. 

Officers.  The  executive  officers  elected  at  the  meeting  on  organization 
arc  Honorary  Chairman,  Major-General  W.C.  Gorgas,  ActiveChairman, 
Dr.    Rupert    Blue,  and  Secretary,  Dr.  Scale  Harris. 

riie  work  of  the  National  Committee  is  divided  among  the  following 
six  subcommittees: 

(1)  Administration. 

(2)  Kiitomology. 

(3)  Medical  Research. 

(4)  Kducation  and  Publicity. 
(.'))   Sanitary  Engineering. 
(6)  Statistics. 

HI.     General  Functions  of  Subcommittees 
The  specific   functions   of   the   subcommittees,  in   detail,  are   given 

below : 

Administration.     The  duties  of  this  comnnttee  shall  be  to  encourage: 
(1)  The  organization  of  the  state  committees  in  afliliation  with   the 

National  Committee 

("i)  The  adoption  of  antini.il;iri;d  iiicasurcs  by  coMiiMMnities. 

('J)    Malarial    surxcys    aiid    (jciiioiisl  ral  ion    of    ant  iiiialarial    work    in 

suitable  communiti(*s. 

(4)  Cooperative  effort  in  malarial  wmk. 

Kntomologtf.     The  duties  of  this  coMuiiit  Ire  shall  be  to  nicotirage: 

(1)  Mosfjuito  surveys. 

(2)  Moscjuito  collections. 

(.S)    Studies  of  entomological  factors  iij  the  nial;iri;i  problem. 
(4)   Mosijuilo  bionomics. 


A  PLAN  FOR  ORGANIZED  PREVENTION 

Medical  Research.     The  duties  of  this  committee  shall  be  to  encourage : 

(1)  Studies  of  the  life  history  of  the  malarial  parasite. 

(2)  Its  effects  oii  man. 

(3)  Means  for  its  destruction  in  man. 

Education  and  Publicity.     The  duties  of  this  committee  shall  be: 

(1)  To  encourage  the  teaching  of  the  facts  of  malaria  and  its  control 
in  the  schools  and  as  far  as  may  be  possible  to  standardize  the  subject- 
matter  and  the  methods  of  so  doing. 

(2)  To  encourage  the  discussion  of  malaria  in  medical  societies  and 
other  interested  bodies. 

(3)  To  arrange  for  popular  lectures  on  malaria  to  adults  and  to 
school-children. 

(4)  To  interest  the  public  press  and  encourage  it  to  carry  on  publicity 
campaigns  on  malaria. 

Sanitary  Engineering.     The  duties  of  this  committee  shall  be : 

(1)  To  encourage  the  employment  of  skilled  sanitary  engineers  by 
communities  contemplating  drainage  and  other  engineering  measures 
for  the  control  of  malaria. 

(2)  To  confer  with  those  engaged  in  drainage  or  impounding  projects, 
so  as  to  obviate  the  establishment  of  disease-breeding  areas. 

Statistics.     The  duties  of  this  committee  shall  be: 

(1)  To  encourage  states  and  minor  civil  divisions  to  record  and 
report  cases  and  deaths  from  malaria  by  localities. 

(2)  To  standardize  methods  of  tabulation  to  be  used  for  this  purpose, 

(3)  To  encourage  the  collection  of  data  relating  to  the  economics  of 
malaria. 

IV.    Ways  and  Means 

In  the  furtherance  of  the  objects  and  purposes  of  the  National  Com- 
mittee on  Malaria  Eradication,  it  would  seem  urgently  advisable  that 
there  should  be  introduced  into  Congress  a  bill  making  provision  for 
adequate  federal  support  on  a  cooperative  basis,  more  or  less  in  con- 
formity to  an  act  of  the  Sixty-third  Congress,  which  provides  for  co- 
operative agricultural  extension  work.  The  sanitary  cooperative  act 
may  be  made  all  inclusive  or  specifically  limited  to  malaria  eradication 
and  control.  If  made  all  inclusive,  the  basis  should  be  on  the  principle 
of  proportionate  contributions,  with  a  due  regard  to  both  area  and  rural 
population.*  No  federal  financial  support  should  be  forthcoming  until 
the  states  and  counties  concerned  have  provided  twice  the  amount 
required.  In  other  words,  if  the  federal  appropriation,  on  the  basis  of 
a  given  population,  for  a  given  area  is,  say,  $10,000  per  annum,  this 
amount  should  not  be  available  until  $20,000  has  been  provided  through 
the  local  authorities.     Since  rural  sanitation  generally  is  so  very  closely 

♦Recommendation  based  on  original  suggestion  by  Dr.  W.  S.  Rankin  at  Southern  Health  Officers'  Confer- 
ence, Washington,  D.  C,  January  29,  1917. 

30 


A  PLAy  FOR  ORGANIZED  PREVEXTWX 

related  to  malaria  eradication,  at  least  in  the  Southern  States,  it  would 
probably  be  advisable,  as  a  practical  consideration,  to  make  the  con- 
gressional appropriation  available  for  sanitary  purposes  generally, 
rather  than  for  malaria  eradication  alone.  The  general  supervision  of 
such  federal  expenditure  should,  of  course,  be  under  the  direction  of  the 
Surgeon-CJeneral  of  the  United  States  Public  Health  Service,  who  should 
make  the  federal  allotment  upon  the  recommendation  of  the  Governor 
of  the  State  and  the  Secretary  of  the  State  Board  of.  Health,  after  the 
required  local  ajjpropriation  had  been  provided  for.  In  the  words  of 
the  Secretary  of  Agriculture,  "the  Extension  Act  is  one  of  the  most 
striking  educatioiud  measures  ever  adopted  by  any  government,"  but 
of  even  greater  practical  importance  would  be  a  sanitary  extension 
act  especially  applicable  to  rural  communities.  The  Agricultural 
Extension  Act  not  only  provides  for  active  cooperation  between  the 
states  and  the  federal  government,  but  "it  guarantees  a  coordination  of 
the  two  forces  of  the  two  jurisdictions.  It  places  the  brains  of  the  two 
great  agencies  in  conjunction,  eliminates  waste  and  friction,  and  insures 
efficiency."  The  act  provides  for  a  gradually  increasing  appropriation 
without  any  further  legislation.  Considering  the  enormous  practical 
value  of  such  legislation  in  the  furtherance  of  intelligent  agricultural 
development,  it  re(|uires  no  argument  to  sustain  the  conclusion  that 
a  similar  extension  act  in  the  direction  of  sanitary  and  general 
|)ublic-health  i)roblems  would  prove  productive  of  far-reaching 
results  to  the  i)ul)lic  at  large.  Every  state  in  the  I'nion  through  its 
[)roper  authority  has  accepted  the  provisions  of  the  Agricultural  Ex- 
tension Act,  and  it  is  a  foregone  conclusion  that  there  would  be  a  similar 
C(>oi)eration  on  the  part  of  all  of  the  states  in  regard  to  the  plan  of 
federal  and  state  sanitary  cooperation.  Aside  from  such  direct  financial 
sui)i)()rt  in  the  de\el(»i)m<Mit  of  rural  sanitation,  it  is  urgently  to  l)e  desired 
that  a  sufficient  amount  should  be  nuide  a\ailal)le  to  the  l'\'dcral  I'ublic 
Health  Service  for  malaria  research  and  demonstration  work.  An 
aj)proi)riation  of  not  less  than  $100, 000  [)er  anmnn  should  be  made  as  a 
guarantee  for  the  continuance  of  the  admirable  work  which  is  at  present 
being  done  by  the  l''ed(M-al  I'ublic  flealth  Ser\ice  in  this  important 
direction.  Malaria  as  a  publi(!-health  problem  is  of  such  vast  im- 
portance to  the  Nation,  that  it  uiiglil  also  be  considered  n(lvisal)le  to 
pro\ide  for  the  establishment  of  a  permanent  Federal  Board  for  Malaria 
l'>radication,  consisting  of  the  Surgeon-(  ien<'ral  of  the  I  iiited  States 
Army,  the  Surgeon-Cieneral  of  the  I'nited  States  I'ublic  Health  Ser\  ii<' 
and  the  Secretary  of  the  Department  of  .Vgrioilture. 

Of  special  interest  in  coimcclion  with  this  suggestion  is  the  enactment 
of  a  law  (liHi)  by  tlu*  Sixty-fourth  Congn'ss  providing  for  federal  aid  to 
the  states  in  the  const  ruction  of  rural  post  roads  and  for  other  purposes. 
The  initial  uppr(»priation  under  this  act  is  ^.'i.OOO.OOO;  for  the  y(>ar 
IQlHthesum  apjjropriated  is  $10,000,000;  for  the  y«'ar  1!)!!).  $l.i.OO0.000; 

81 


A  PLAX  FOR  ORGANIZED  PREVEXTIOX 

for  the  year  1920,  $20,000,000,  and  for  the  year  1921,  $25,000,000.  The 
federal  appropriation  to  the  states  becomes  available  on  the  required 
amount  being  certified  to  by  the  State  Highways  Department  and  the 
State  Governor.  Any  state  desiring  to  avail  itself  of  the  benefits  of  this 
act  through  its  State  Highways  Department  is  required  to  submit  to  the 
Secretary  of  Agriculture  such  a  project  statement,  setting  forth  the 
proposed  construction  of  any  rural  post  road  or  roads,  service,  plans, 
specifications  and  estimates,  as  the  Secretary  of  Agriculture  may  require. 
In  much  the  same  manner  an  appropriation  for  federal  sanitary 
cooperation  could  be  carried  into  effect  under  the  immediate  direction  of 
the  Federal  Public  Health  Service,  the  State  Board  of  Health  and  the 
State  Governor. 

V.    Federal  Departmental  Cooperation 
The  keynote  of  an  active  federal  campaign  against  malaria  is  the  clear 
recognition  of  the  supreme  importance  of  the  most  effective  and  active 
cooperation  of  federal  governmental  department  chiefs,  including  among 
those  essential  to  the  purpose: 

(a)  The  Surgeon-General  of  the  United  States  Army, 
(6)  The  Surgeon-General  of  the  United  States  Navy. 

(c)  The  Surgeon-General  of  the  United  States  Public  Health  Service. 

(d)  The  Chief  of  Engineers  of  the  United  States  Army. 

(e)  The  President  of  the  Mississippi  River  Commission. 
(/)  The  Director  of  the  United  States  Geological  Survey. 
(g)  The  Director  of  the  United  States  Reclamation  Service. 

(h)  The  Director  of  the  Office  of  Public  Roads  and  Rural  Engineering. 

(i)   The  Chief  of  the  United  States  Weather  Bureau. 

( j)  The  Chief  of  the  United  States  Bureau  of  Soils. 

(k)  The  Chief  of  the  United  States  Bureau  of  Entomology. 

(/)    The  Chief  of  the  United  States  Bureau  of  Fisheries. 

(m)  The  Chief  of  the  Division  of  Vital  Statistics  United  States  Census. 

(n)  The  Chief  of  the  States  Relations  Service. 

(o)  The  Federal  Farm  Loan  Board, 

(p)  The  United  States  Commissioner  of  Labor  Statistics. 

VL     Pan-American  Cooperation 

In  view  of  the  fact  that  the  official  text  of  the  resolution  of  the  Second 

Pan-American  Scientific  Congress  (Article  39)  suggests  that 

The  American  Republics  inaugurate  a  well-considered  plan  of  malaria  eradica- 
tion, based  upon  the  recognition  of  the  principle  that  the  disease  is  preventable 
to  a  much  larger  degree  than  has  thus  far  been  achieved. 

It  is  implied  and  required  that  there  should  be  the  most  hearty 
cooperation  between  the  American  Republics  as  officially  represented  in 
the  United  States  by  the  Director-General  of  the  Pan-American  Union, 
particularly  in  the  direction  of  the  most  effective  publicity  of  all  impor- 
tant matters  relating  to  the  suggestions  and  recommendations  of  the 
National  Committee  for  the  information  of  the  Latin-American  countries 

32 


A  FLAX  FOR  ORGAMZFJ)  FRFA'FXTIOX 

through  the  medium  of  the  Monthly  Bulletin  of  the  Fan- American 
Union.  In  addition  thereto,  the  assistance  of  the  Chief  of  the  Division 
of  Latin-American  Affairs  of  the  Department  of  State  might  be  enlisted 
in  behalf  of  an  efl'ort  to  bring  about  the  cooperation  of  the  American 
Republics  agreed  upon  as  desirable  and  essential  in  the  resolution  re- 
ferred to.  It  is,  furthermore,  self-evident  that  the  subject  of  malaria 
eradication  should  engage  the  most  serious  attention  of  the  International 
Sanitary  Congress  at  its  fortlicoming  session  and  that  adequate  pro- 
vision should  be  made  sufficiently  in  advance  to  provide  for  the  most 
thorough  scientific  consideration  of  the  problem  of  malaria  eradication 
in  its  international  aspects  at  the  Third  Pan-American  Scientific  Con- 
gress agreed  upon  to  be  held  in  Lima,  Peru,  in  1920.* 

The  first  of  the  ]*an-American  (jovernments  to  make  provision  for 
malaria  eradication  is  the  Republic  of  Peru.  According  to  a  recent  law- 
passed  by  the  Peruvian  congress  and  approved  by  the  president,  subse- 
quently to  be  enlarged  upon  by  state  regulations,  malaria-eradication 
measures  will  be  classified  in  four  sections,  namely,  the  treatment  of 
patients,  the  i)rotection  of  people  living  in  places  where  malaria  is 
recognized  as  endemic,  the  destruction  of  mosquitoes  and  the  drainage 
or  special  treatment  of  swampy  lands.  According  to  a  report  of  the 
JJuroau  of  Domestic  and  Foreign  Commerce,  the  Peruvian  (io\ernment, 
in  connection  with  the  antimalaria  cami)aign,  "will  import  annually 
such  a  (piantity  of  (juinine  as  may  be  considered  necessary,  and  this 
drug  will  be  imported  free  of  all  customs  duties  and  port  charges. 
Individuals  and  institutions  may  purchase  rjuininc  of  the  (lovernmcnt 
at  cost  jjrice  for  their  own  use  and  for  the  treatment  of  persons  under 
their  charge.  .\11  i)roj)rietors  of  estates,  all  railways,  corporations,  and 
other  organizations  enii)loying  labor  are  under  obligations  to  furnish 
medical  assistance  to  their  employees,  either  directly  or  through  pro- 
I)ortionate  contributions  to  charitable  dispensaries,  and  insp<*clors  will 
i)e  ap|)ointed  to  see  that  this  part  of  the  work  receives  due  attention. 
I'nemployed  persons  will  receive  free  quinine  from  the  (iovernment. 
For  the  protection  of  |)crsons  living  in  swampy  districts,  houses  nuist  be 
ecjuijiped  with  mos(|uilo-proof  netting,  and  rice  or  other  crops  re<|uiring 
flofxling  nuist  not  be  cultivated  within  a  ccrfain  distance  of  habitations." 

According  to  the  same  report  the  Peruvian  (ioxcrnmenl  "will  at  once 
begin  the  work  of  draining  the  lands  where  malaria  is  most  prevalent, 
and  all  private  owners  are  given  from  one  to  four  years  lo  complete  the 
sanitation  (»f  their  hmds.  When-  drainage  is  impracticable,  swamps 
are  to  be  treated  with  crude  petroleum  to  destroy  insects  and  their 
larvae,     'i'he  (i()V<*rnment  is  authorized  to  give  prizes  and  honors  to 

The  plan  and  Kiipc  uf  tlir  work  of  thr  Inlrrnulional  IIIkIi  CotiiDiiwion  Ho  do(  at  prrtriil  proviilr  (or  Ihr 
conai<lrrH(ioii  of  brnllli  iiml  (iinilnry  prol<|rtiii.  Il  woulil  irrm  clr»irnli|r  to  inrrrax'  the  final  pr<i);rani  of  th<" 
comnii.ijiion  hi  net  (urlli  in  lli<-  rrporl  n(  llir  Tnili-d  Shilra  Srrtion  on  tlir  fimt  itrnrrnl  nirrliiiK.  Ii'ltl  at  lliirno* 
Aim,  April  3  to  \i,  lllld,  liy  Ihr  lulilitinn  of  n  (oiirtPrnth  irrlion,  on  I'liMir  ili-nlth  nml  IntrrnBliimal  Qiiaran- 
linr.  Hy  mrana  of  iinrli  a  urction  tlir  iiilijrct  of  malaria  rrailii  alinn  in  it*  I'Mn-Anirriian  aaprri*  would  hr 
appropriatrly  IitoukIiI  lo  Ihr  attrnlion  of  the  rr»pr<  livr  itovrrnnirnl*  contrrnrd  and  |H>uildy  rarlirr  tlian  at 
thr  inrrtinK  of  th<'  lliini  I'liii-AnK'riian  Si  iinlilii  Conitrrii*,  in  IIWO. 


A  PL  AX  FOR  ORG  AM  ZED  PRFA^EXTION 

proprietors  who  show  the  most  zeal  in  putting  their  lands  into  good 
condition.  An  exhaustive  study  is  to  be  made  of  modern  irrigation  and 
cultivation  systems,  with  a  view  to  overcoming  the  farming  conditions 
that  lead  to  malaria.  In  addition,  a  course  of  study  on  the  prevention 
of  malaria  is  to  be  introduced  in  all  the  public  and  private  schools  of 
Peru.  This  instruction,  as  well  as  the  organization  and  maintenance  of 
the  sanitary  work,  will  be  in  charge  of  the  Department  of  Public  Health, 
and  the  expense  incurred  wnll  be  met  by  annual  appropriations  in  the 
budget." 

The  Peruvian  Government  is  entitled  to  the  high  honor  of  having  been 
the  first  of  the  Pan-American  Republics  to  carry  into  actual  effect  the 
provisions  of  Article  39  of  the  Final  Act  of  the  Second  Pan-American 
Scientific  Congress,  and  the  results  to  be  achieved  under  the  contem- 
plated measures  of  eradication  should  make  a  most  useful  and  instruc- 
tive contribution  to  the  proceedings  of  the  Third  Pan-American  Scientific 
Congress,  to  be  held  in  Lima,  Peru,  in  1920. 

VII.     State  Cooperation 

On  the  part  of  each  of  the  states  most  seriously  interested  in  malaria 
eradication,  the  problem  in  its  final  analysis  is  chiefly  a  matter  of 
local  concern,  and  the  required  funds  for  such  objects  and  plans  as 
may  be  deemed  advisable  must  be  derived  from  state  and  local  rev- 
enues, except  in  so  far  as  they  may  be  amplified  by  corresponding 
amounts  made  available  through  federal  appropriations.*  It  is,  how- 
ever, essential  that  there  should  be  on  the  part  of  each  and  every  state 
directly  concerned  the  most  thoroughly  considered  cooperation  on  the 
part  of 

(a)  The  State  Board  of  Health. 

(6)  The  State  Engineering,  Drainage  or  Reclamation  Commission. 

(c)  The  State  Geological  Survey. 

(d)  The  scientific  departments  of  the  State  University,  useful  in  the 
rendering  of  assistance  in  the  furtherance  of  the  plans  of  the  National 
Committee. 

(e)  The  State  Agricultural  Experiment  Station. 
(/)  The  State  Medical  Society'. 

VIII.     County  and  Municipal  Cooperation 

Malaria,  in  general  terms,  being  largely  a  local  problem,  particularly 
as  regards  mosquito  eradication,  it  is  of  the  utmost  urgency  that  the 
most  carefully  considered  cooperation  should  be  had  on  the  part  of  the 
counties  and  municipalities  in  which  malarial  disease  is  known  to  prevail 

*This  suggestion  is  merely  tentative.  The  underlying  consideration  is  the  excellent  work  of  the  States 
Relations  Service  of  the  United  States  Department  of  Agriculture,  which  represents  the  Secretary  of  Agri- 
culture in  his  relations  with  Stale  Agricultural  Colleges  and  Experiment  Stations,  under  the  acts  of  Congress 
granting  funds  to  these  institutions  for  experimental  and  cooperative  extension  work  in  agriculture  and  home 
economics,  in  carrying  out  the  provisions  of  act-i  of  Congress  making  appropriations  to  this  department  for 
farmers'  cooperative  demonstration  work,  investigations  relating  to  agricultural  schjols,  farmers'  institutes 
and  home  economics,  etc. 

34 


A  PLAX  FOR  ORGANIZED  PREVEXTIOX 

to  a  more  or  less  serious  degree.     It  is  therefore  suggested  as  essential 
that    the  cooperation  of  the  following  should  be  enlisted: 

(a)  The  City  or  County  Board  of  Health. 

(b)  The  City  or  County  Engineer. 

(c)  The  Department  of  Public  Works  or  kindred  bodies  having  to 
do  with  sewerage  and  drainage. 

(d)  Local  medical  societies. 

IX.     International,  National  and  Corporate  Health-Promoting 

Agencies 

In  addition  to  fedoral,  state  and  local  governmental  cooijcration.  all 
of  the  more  imj)ortant  international,  national  and  corporate  health- 
promoting  agencies  should  be  utilized  in  the  furtherance  of  the  practical, 
as  well  as  theoretical,  work  of  the  National  Committee.  Of  these 
agencies,  the  following  are  of  special  importance: 

(a)  The  International  Health  Commission  (already  actively  engaged 
in  malarial  research  and  eradication  in  certain  Southern  States).* 

(b)  The  Carnegie  Institution  (which  has  rendered  a  most  conspicuous 
service  to  the  cause  of  malaria  eradication  by  the  publication  of  a 
thoroughly  scientific  treatise,  in  four  volumes,  on  "The  Mos- 
quitoes of  North  and  Central  .Vmerica  and  the  West  Indies,"  by 
Leland  O.  Howard,  Harrison  G.  Dyar  and  Frederick  Knab). 

(c)  The  American  Public  Health  Association,  especially  through  the 
Section  on  Sanitary  P^ngineering. 

(d)  The  Southern  Sociological  Congress. 

(e)  The  American  Medical  Association. 
(/)  The  Southern  Medical  Association. 
(g)  The  American  Academy  of  Medicine. 

(h)  The  American  Climatological  Association. 

(i)    The  American  .Ysstxrialion  of  Kconomic  Entomologists. 

(j)   The  American  Micro.scopical  Society. 

(k)  The  American  Nature  Study  Society. 

(/)    The  .XmericaM  Society  of  Civil  Engineers. 

(w)  The  American  Museiun  of  Natural  History. 

(")  The  American  Hospital  A.ssociation. 


•Kxlr»ct  from  Srcond  Anniinl  RrjMirl  of  thr  IntrrnBtiotikl  llrnlth  Commiuion.  1018: 

"Throretif«Ily.  the  control  of  mnlnria  is  rrlativrly  limplr,  l>iil  aji  >  prarliml  iiti'lrrtakinf  it  ha*  b«*n 
found  rxtmnrly  iliflicull.  In  virw  of  thr  important  intrrrstf  at  stakr,  howrvrr,  thr  Intrrnational  llrajtb 
CommiMion  in  iinilrrtakinx  to  rarry  out  an  ri|MTiinrnl  with  a  virw  to  ascrrtaininK  what  .Ir^rrr  of  control  may 
be  achirvrd  in  our  Irmprralr  climntr  within  thr  liniit.i  of  rrajunatilr  rx|M-niliturr  an<l  umlrr  ''  '         •• 

which  prevail  in  typirnl  furmiiiK  •■oiiiniunilirg  in  thr  >(iiithrrn  >t«lr».     Arrniitfrnirnli  havr  \>rrn  > 

out  two  »rls  of  rx|H:riinrn(s,  onr  lo  lint  thr  prn<-ti<'nliillt.v  of  ninlaria  lonlrol  \>y  <|rlrrtin(l  thr  rarr  - 

lag  thrm  of  thr  parasiira;  and  thr  othrr  to  trat  thr  prartirahility  of  malaria  runlrul  by  mean*  u(  a  >umt»aa- 
tioo  of  control  mraaurr*.  In  nrilhrr  raar  ii  the  rxlrrmination  of  moafjuitora  by  major  drainafr  oprratiou  to 
b*  undrrtakrn." 

S5 


A  PL  AX  FOR  ORG  AM  ZED  PRFA'KXTIOX 

X.     Education  and  Publicity 

Since  all  measures  and  means  for  malaria  prophylaxis  must  rest 
primarily  for  their  highest  obtainable  degree  of  effectiveness  upon  the 
intelligent,  most  hearty  and  continued  cooperation  of  the  general  public,* 
it  is  of  the  first  order  of  importance  that  qualified  assistance  should  be 
rendered  in  behalf  of  this  effort  by 

(a)  The  United  States  Bureau  of  Education. 

(6)  The  state,  county  and  municipal  educational  authorities. 

(c)  The  Council  on  Health  and  Public  Instruction  of  the  American 
Medical  Association. 

(d)  The  General  Federation  of  Women's  Clubs, 

(e)  The  press,  whether  general,  medical  or  technical,  including  period- 
icals and  the  general  press  service  of  the  Associated  Press,  the 
American  Press  Association,  the  International  News  Service,  the 
United  Press  Association,  etc. 

(/)  The  mosquito  extermination  associations. 

(The  New  Jersey  association  has  held  four  annual  meetings  to 
date  and  has  rendered  conspicuous  educational  services.  Thc^ 
proceedings  are  a  most  valuable  source  of  useful  information. 
According  to  an  address  by  Dr.  Ulrich  Dahlgren,  the  number  o  { 
cases  of  malaria  in  Princeton,  N.  J.,  was,  in  consequence  of  loca  I 
antimalarial  measures,  reduced  from  127  in  1914  to  only  8  ii  i 
1916.) 

XI.     Industrial  and  Other  Corporate  Business  Organizations 

(a)  The  Chamber  of  Commerce  of  the  United  States  of  America 
(This  body  has  already  indicated  its  interest  in  the  subject,  by 
the  publication  of  a  special  bulletin  on  "Reclamation  of  Swamp 
Lands  and  Conquest  of  the  Malaria-bearing  Mosquito,"  Wash- 
ington, D.  C,  October  27,  1916.) 

(6)  Local  chambers  of  commerce  and  boards  of  trade. 

(c)  The  Southern  Commercial  Congress. 

(d)  The  National  Civic  Federation. 

(e)  The  National  Farmers' Congress. 

(/)  The  National  Rivers  and  Harbors  Congress. 

ig)  The  Atlantic  Deeper  Waterways  Association. 

(h)  Southern  railway  companies  and  river  transportation  lines. 

(i)  Steamship  companies  engaged  in  Southern  coastwise  or  Latin- 
American  commerce. 

( j)  Life  insurance  companies  and  societies  transacting  business  in  the 
Southern  States  and  Latin-American  countries. 

(k)  The  Life  Extension  Institute. 

♦Of  considerable  practical  value  is  a  brief  "Summary  of  Facts  Regarding  Malaria  Suitable  for  Public 
Instruction,"  by  Maj.  (now  Sir)  Ronald  Ross,  published  by  John  Murray,  London,  1911.  This  summary 
includes  a  descriptive  account  of  the  relation  of  the  parasites  to  malaria,  the  mode  of  infection,  the  essential 
facts  about  mosquitoes,  the  means  of  personal  prevention  and  the  means  of  public  prevention.  The  outline 
concludes  with  the  suggestion  that  "for  further  information  or  assistance  the  reader  should  apply  to  the  local 
tanitary  or  medical  authorities." 

3G 


A  PLAS  I'ORORCAMZEI)  PRFA'K.\TI(}.\ 

XII.     An  Active  Advisory  Council 

An  active  advisory  council  might  be  formed  and  made  to  consist 
of  official  representatives  of  the  foregoing  and  kindred  bodies  or  organiza- 
tions and  agencies  useful  for  the  purpose  of  furthering  by  their  active 
©operation  or  by  means  of  correspondence,  etc.,  the  plans  and  purposes 
of  the  National  Committee  on  Malaria.  The  council  should  meet  with 
the  National  Committee  at  least  once  a  year  in  the  city  of  Washington, 
so  as  to  bring  about  the  most  satisfactory  coordination  of  federal,  state 
and  other  interests. 

XIII.     Some  General  Methods  of  Procedure 

A.  Malarial  Surveys  and  Public  Education 

Among  the  more  important  methods  and  means  in  behalf  of  active 
eflForts  at  malaria  eradication  the  following  are  deserving  of  special 
consideration : 

(a)  Malaria  and  mosquito  surveys.  For  an  excellent  illustration,  see 
Bulletin  189,  Connecticut  Agricultural  Experiment  Station,  en- 
titled "A  Mosquito  Survey  at  the  Mouth  of  the  Connecticut 
River."  The  special  importance  of  this  survey  is  that  the  ex- 
pense of  making  the  same  was  met  by  the  Old  Saybrook  Town 
Improvement  Association  of  Old  Saybrook,  Conn. 

One  of  the  most  instructive  of  the  many  mosquito  surveys 
made  in  this  country  is  the  Report  on  Mosquito  Investigations, 
by  W.  E.  Britton  and  Harry  Viereck,  in  the  Connecticut  Experi- 
ment Station  Rej)ort  for  1904,  including  observations  on  tlie  char- 
acteristic vegetation,  as  a  guide  to  the  ascertainment  of  mosquito- 
breeding  areas,  and  descriptive  accounts,  illustrated  by  maps,  of 
the  most  affected  area^s  in  the  state.  The  rei)ort  concludes  with 
practical  suggestions  on  mosquito  control  in  Connecticut  and 
on  the  relation  of  nio.squitoes  to  proi)erty  values. 

An  excellent  account  of  modern  methods  in  making  anopheles 
surveys,  with  extended  lists  of  anopheles  breeding-places  through- 
out different  health  districts  of  the  colony,  is  et)ntained  in  the 
Trinidud  Malarial  ]^'po^l  for  1  !>  11-1 !)!."),  by  Dr.  C.  F.  Lassalle/i'riii- 
idad,  1!)1(>.  Nine  diflerent  types  of  breeding-areas  are  defined,  as 
follow.s:  (1)  Slowly  running  water-courses,  streams  and  rivers, 
i'i)  I'ools  in  ravines  ravines  are  water-courses  which  are  generally 
dry  during  the  dry  season  and  contain  pools  during  the  rainy 
season.  (3)  l/ow-lying  swampy  and  grassy  land  bordering  on 
extensive  mangrove  swamps  — containing  large  and  small  depres- 
sions, crab-holes,  etc.,  (4)  Rice  fields,  (.5)  I*onds,  ((J)  Shallow  wells 
and  water-holes,  (7)  IJorrow-pits  at  tin- sides  of  roads  and  railwa\ 
lines,  (H)  "Tapia"  holes  holes  from  wlii«li  cliiy  is  obtained  for 
building  huts,  (ft)  Earthen  street  and  road  drains  improperly 
graded   or   blocked.      Of   s|(ccial    pracli<id    inten-st    are  tin"  fornix 


A  PLAN  FOR  ORGANIZED  PREVENTION 

used  in  the  anopheles  survey  of  Trinidad  and  the  instructions  to 
assistant  sanitary  inspectors. 

(b)  Malarial  indices,  primarily  of  children,  through  the  medium  of 
medical  school  inspection  and  of  factory  employees  through  the 
physical  examination  of  applicants  for  work. 

Some  interesting  observations  on  the  methods  of  obtaining 
children  for  spleen  examinations,  and  the  practical  difficulties 
to  be  overcome,  are  included  in  the  notes  on  Sumatra  in  Malcolm 
Watson's  treatise  on  "Rural  Sanitation  in  the  Tropics."  In  the 
same  work  is  a  brief  discussion  of  erroneous  or  misleading  spleen 
rates  in  correlation  to  malaria  death  rates  in  British  Guiana.  The 
most  important  recent  contribution  to  this  subject  is  "The  Spleen 
Census  for  1914,"  of  the  island  of  Trinidad,  by  C.  F.  Lassalle, 
acting  assistant  medical  officer  of  health,  in  the  Trinidad  Malarial 
Report.  According  to  this  census  the  percentage  of  children  with 
enlarged  spleens  in  the  colony  was  14.1  per  cent.  The  corre- 
sponding percentages  obtained  for  other  countries,  as  given  in  the 
report,  for  comparatively  recent  years,  are  34.1  for  Mauritius, 
34.1  for  Ceylon,  and  17.9  for  Trinidad  and  Tobago,  during  1913- 
1914,  which,  therefore,  indicates  a  decline  during  the  year  1914, 
when  the  ascertained  percentage,  as  previously  stated,  was  14.1. 
The  maximum  spleen  rate  in  1914,  for  the  Oropouche  and 
La  Brea  districts,  was  57.7  per  cent.  The  lowest  rate  prevailed 
in  the  Arima  district,  or  1.1  per  cent.  A  brief  but  exceptionally 
useful  practical  contribution  to  American  malarial  index  work  is 
reprint  159,  by  the  late  R.  H.  von  Ezdorf,  M.  D.,  of  the  United 
States  Public  Health  Service,  Washington,  1914. 

(c)  Public  education,  chiefly  through  the  public  schools,  more  or  less 
in  conformity  to  the  essential  principles  of  "Malaria,  Lessons  on  Its 
Cause  and  Prevention,"  by  Dr.  H.  R.  Carter  of  the  United  States 
Public  Health  Service,  and  the  broad  outlines  of  malaria  prevention 
as  laid  down  in  Bulletin  No.  10  of  the  Medical  Series  of  the 
University  of  Missouri,-  by  Prof.  Elbert  L.  Spence. 

(d)  Medical  education,  in  the  furtherance  of  improvements  in  clinical 
and  microscopical  diagnoses  of  malarial  disease,  in  the  more 
accurate  differentiation  of  the  several  types  of  malaria  and  accu- 
racy in  death  certification,  chiefly  with  reference  to  joint  causes 
or  diseases  in  which  malaria  is  a  contributory  or  complicating  cause. 

B.  Free  Microscopical  Examinations 

Public  facilities  should  be  provided  for  the  free  microscopical  exam- 
ination of  the  blood  for  the  diagnosis  of  malaria  and  the  ascertainment 
of  the  presence  or  absence  of  the  malarial  parasites,  the  nature  of  the  pig- 
ment and  leucocytosis,  and  the  numeric  relation  of  the  leucocytes,  as 
laid  down  in  the  standard  text-books  on  malaria,  and  the  laboratory 
examination  of  the  blood. 

38 


A  PLAX  FOR  ORG  AM  ZED  PREVKXTIOX 

The  practical  difficulties  of  blood  examinations  are  the  subject  of  an 
extended  discussion  by  the  Director  of  the  Wellcome  Tropical  Research 
Laboratories,  Andrew  Balfour,  M.  D.,  Gordon  Memorial  College, 
Khartoum,  in  the  fourth  report  of  that  institution,  issued  in  1911. 
The  general  subject  of  microscopical  examination  of  the  blood  in  malaria 
is  discussed  with  admirable  brevity  in  the  second  chapter  of  Sir  Patrick 
Manson's  treatise  on  "Tropical  Diseases,"  who  observes  that  "For 
a  thorough  appreciation  of  the  principles  on  which  t)lood  examinations 
for  the  demonstration  and  study  of  the  malaria  parasite  should  be  con- 
ducted, it  must  be  borne  in  mind  that  the  parasite  is  intracorpuscular. 
To  see  it,  therefore,  it  is  necessary,  particularly  for  the  beginner,  so  to 
dispose  of  the  corpuscles  in  the  preparations  that  a  proportion  of  them 
shall  lie  flat  on  the  slide,  in  a  single  layer,  and  presenting  their  surfaces, 
and  not  their  edges,  to  the  observer.  It  is  mainly  from  ignoring  this 
fundamental  principle  that  so  many  fail  to  find  the  parasite." 

For  the  same  reason  it  is  particularly  urgent  that  the  use  of  the 
microscope  on  the  part  of  practising  country  physicians  should  become 
more  general,  in  fact,  universal.  It  has  been  said  in  this  connection 
by  Deaderick  that 

Before  attempting  the  diagnosis  of  malaria  by  the  microscopic  e.xamination 
of  the  blood  the  beginner  must  become  thoroughly  familiar  with  the  appearance 
of  normal  blood  and  with  the  technic  of  examination,  and  he  should  not  rely  too 
much  upon  the  result  of  an  examination  until  he  has  had  considerable  experience 
with  malarial  blood. 

C.  Collection  and  Preservation  of  Mosquitoes 

Ix)cal  collections  of  prevailing  species  of  moscjuitoes  and  their  proper 
preservation,  in  conformity  to  the  methods  of  the  American  Museum 
of  Natural  History,  are  a  first  essential  in  the  education  of  school-children 
and  the  public  as  regards  the  required  differentiation  of  malaria-carrying 
mo.squitoes  and  mosquitoes  harmless  in  this  respect. 

The  collection  and  i)reservalion  of  mosquitoes  in  conformity  to  exact 
.scientific  re(piirements  are,  of  course,  much  more  difficult  than  is  generally 
a.ssumed  to  be  the  ca.se.  It  is  also  far  too  generally  assumed  that  most 
of  the  rec|iiired  information  concerning  the  geograpliical  distribution  of 
the  different  species  of  moscpiitoes  is  already  known  and  liiat  further 
research  i.s,  therefore,  unnecessary.  An  excellent  illustration  of  the 
results  of  strictly  scientifi<-  work  in  this  field  is  a  descriptive  account  of 
"New  Mos(|uil<)es  from  the  Soudan,"  by  Fred  \  .  Tlieol)al(i,  in  the  Third 
Ref)ort  of  the  Weilcoriu'  Hescanli  Laboratory,  Kartoum.  1!>0S.  A  care- 
fully j)repared  guide-book  on  "How  to  Collect  au<l  IVi-scrve  Insects" 
was  pul)lished  l)y  Frank  E.  Lutz  of  tli<'  .\iiicri(  .in  Mns<iiin  of  Natural 
History,  New  ^'ork  City.  1J)15.  .Miention  nuiy  be  directed  in  this  con- 
nection to  "Instructions  to  Collectors  of  Sp»'ciriiens  for  tlie  Central 
Malaria  Hureau."  drawn  up  by  tin-  Connnitte<'  for  tin*  Study  of  Malaria 
in  India,  published  in  Simla.  I!)!';.',  "Not«vs  on  the  Mos(|uiloes  of  the 
United    States."    by    L.    ().    How.inl,    lulled    States    ne|>artnuMit    of 


A  PL  AX  FOR  ORG  AM  ZED  PRFA'EXTIOX 

Agriculture,  Washington,  1900,  and  Publication  No.  VII  of  the  British 
Museum's  Series  of  Instructions  to  Collectors  of  Blood  Sucking  Insects, 
London,  1907. 

D.  Enforcement  of  Local  Ordinances 

Antimalarial  ordinances  and  their  proper  enforcement  are  matters  of 
most  serious  concern  in  connection  with  any  and  all  efforts  at  malaria 
eradication.  In  New  Jersey,  according  to  a  report  of  the  United 
States  Public  Health  Service  on  Communicable  Diseases,  "The  Statf; 
Agricultural  Experiment  Station  is  required  by  law  to  make,  at  the; 
request  of  local  authorities,  an  investigation  into  the  causes  responsible 
for  the  existence  of  mosquitoes  in  any  locality  and  suggest  measures  to 
abolish  them.  The  local  health  authorities  must  be  informed  of  the 
findings  and  they  in  turn  are  required  to  notify  property  owners  of  their 
duty  to  remedy  the  conditions  responsible  for  the  breeding  of  mos- 
quitoes, and  should  the  owners  fail  to  do  this,  the  local  authorities  may 
take  the  necessary  measures,  the  cost  to  become  a  lien  on  the  prop- 
erty." Provision  is  made  in  New  Jersey  for  state  and  municipal 
cooperation  and  the  appointment  in  each  county  of  mosquito  extermina- 
tion commissions,  the  amount  of  money  necessary  for  the  discharge  of 
their  duties  being  included  annually  in  the  tax  levy.  Much  valuable 
additional  information  concerning  law  and  legislation  with  reference  to 
insects  capable  of  transmitting  disease  is  contained  in  the  report  referred 
to,  as  well  as  in  supplementary  publications  on  municipal  ordinances, 
rules  and  regulations  pertaining  to  public  health  adopted  by  cities  of  the 
United  States  having  a  population  of  over  10,000  in  1910.  A  typical 
ordinance  in  this  connection  is  the  following,  adopted  by  the  city  of 
Chattanooga,  Tenn.,  under  date  of  March  10,  1913: 

Be  it  ordained  by  the  board  of  commissioners  of  the  eitj-  of  Chattanooga,  Tenn.  , 
That  it  shall  be  unla^\■ful  for  any  owner,  tenant,  or  agent,  in  control  of  any  lo  t 
or  premises  ^\-ithin  the  corporate  Hmits  to  permit  to  remain  thereon  any  emptj  ' 
bottles,  empty  cans,  or  other  receptacles  likely  to  gather  and  hold  water.  Anc  I 
any  such  owner,  tenant,  or  agent,  failing  to  remove  all  such  articles  from  his  lot' 
or  premises  ■nithin  five  days  after  notice  from  the  department  of  health  to  do  so, 
shall  be  guiltj'  of  a  misdemeanor,  and  upon  conviction  shall  be  punished  bj'  a 
fine  of  not  less  than  $2  nor  more  than  SIO  for  each  offense. 

The  full  text  of  the  New  Jersey  law  with  reference  to  the  prevention 
of  the  breeding  of  mosquitoes,  adopted  under  date  of  May  21,  1912,  is 
republished  in  the  report  on  state  laws  and  regulations  pertaining  to 
public  health  issued  by  the  United  States  Public  Health  Service  as 
reprint  No.  200,  Washington,  1915. 

E.  State  Drainage  Commissions 

Active  efforts  are  required  in  behalf  of  the  establishment  of  State 
Drainage  Commissions  and  drainage  districts  for  the  earliest  possible 
elimination  or  reduction  of  overflowed  areas  or  swamp-lands  which  under 
existing  conditions  are  useless  for  agricultural  purposes  and  a  serious 
menace  to  health  and  life. 

40 


A  PLAN  FOR  ORG  AX  I  ZED  PRFJ'KXTIOX 

The  principles  of  engineering  for  land-drainage  and  the  reclamation  of 
water-injured  lands  have  during  recent  years  been  worked  out  with 
remarkable  thoroughness.  Tidal  marshes  and  their  reclamation  have 
been  reported  upon  by  Mr.  George  M.  Warren,  Drainage  Engineer  of  the 
United  States  Department  of  Agriculture,  and  the  same  office  has  issued  a 
suggestive  report  on  "Drainage  by  Means  of  Pumps,"  by  S.  M.  Wood- 
ward, Drainage  Engineer.  A  very  useful  manual  on  "Drainage  and 
Reclamation  of  Overflowed  Lands"  has  been  issued  by  the  Bureau  of 
Legislative  Information  of  the  State  of  Indiana,  and  the  general  subject 
of  the  "Drainage  of  Farm  Lands,"  has  been  reported  upon  by  C.  G.  Elliott, 
Drainage  Expert  of  the  United  States  Department  of  Agriculture.  The 
general  principles  of  the  establishment  of  a  drainage  fund  are  set  forth 
in  a  report  submitted  by  Mr.  Flint,  of  the  Committee  on  Pul)lic 
Lands,  and  i.ssued  as  a  Senate  Document  (Report  No.  734'2,  59th  Con- 
gress, 2d  Session,  1907).  The  general  subject  of  drainage  has  received 
occasional,  but  far  from  sufficient,  consideration  by  the  Atlantic 
Deeper  Waterways  Association  and  the  National  Rivers  and  Harbors 
Congress.  Perhaps  the  most  important  practical  work  in  this  direction 
has  been  done  in  the  state  of  Arkansas,  as  set  forth  in  a  Report  on  the  St. 
Francis  Valley  Drainage  Project  in  Northeastern  Arkansas;  but  special 
mention  requires  to  l)e  made  of  the  truly  astonishing  results  which  have 
been  achieved  under  the  drainage  district  laws  of  the  state  of  North 
Carolina.  A  general  statement  on  Swamp  and  Overflowed  Lands  in  the 
United  States,  with  reference  to  ownership  and  reclamation,  l)y  J.  O. 
Wright,  Supervising  Drainage  Engineer,  has  been  issued  by  the 
Dej)artment  of  Agriculture.  Washington  1907  * 
F.  Schools  for  Tropical  Medicine 

More  adequate  support  is  required  for  American  Schools  of  Tropical 
Medicine,  for  the  pur{)()sc  of  j)roviding  ways  and  means  for  thoroughly 
s{)eciali/.ed  scientific  iuxcstigatioiis  of  the  geographical  distril)ution 
of  malaria  throughout  the  western  hemisphere  and  of  the  achievements 
and  possibilities  of  malaria  eradication  in  the  countries  of  Latin  America 
in  which  the  disease  is  known  to  j)ie\ail  to  a  more  or  less  considerable 
degree.  Increased  support  is  also  needed  for  the  more  scientific  study 
of  blackwater  fever  and  an}'  and  all  alli<'(l  tro|)ical  diseases  increased  in 
frequency  or  severity  on  account  of  being  complicated  by  malaria,  t 

Ci.   Non-("ontij{uou.s  I'osscssion.s  of  the  I'nited  .Stattvs 
'i  he  active  cooperation  of  the  National  ( 'oniiniltee  with  the  authorities 
of    the    non-contignoiis    possessions    the    United   States  represents   an 

•S<-f  Kiillrtin  No.  MH,  "DrjiiniiK'*  !<»»'  <>f  llx"  Slulc  of  South  <'iirolinii,"  of  the  Sinic  Drpnrlinriit  of  Aifri 
nillurc,  ('oniiDprc-c  niiil  liidii^ilric.i,  ('oliiinl)iii,  11114.  .Mho.  tlir  I'riM'ccilinK'i  of  thr  llliiioii  Aiiniinl  l>riiiiin»(i- 
('oiif<Ti-ii<r,  iiikIit  Ihr  (lin-rtioii  of  Ihr  Colli'Hr  of  Knt{iiii-<'riiiK.  I'nivcTsil.v  <.f  Illinois,  (rliiiiiii.  lllitioi>. 

tOf  viiliK-  ii<i  ronvc-iiiiMil  tiMirrr*  of  Iriiil  worlliy  iiifor unit  ion  iin- 1  In-  itiiniial  r<-|>orl:t  of  tlir  .\i|vi«)r.v  Coniiiiittrr 
of  till'  Tropiriil  I >i!«'ii!ir.«  l(('<iiMir>'li  h'liinl,  iiiilili.tlii-il  ihimiiiiII.v  liy  onlrr  of  I'lirlliiiiK'nt  uiiil  roiitniiiiiiK  <'x(<'ndr<J 
iii'i'oiintii  of  iiiitiiiiiiliiriiil  iiiriiHiirr<i  iiml  ri"iult»  lliroiiKlioiit  tin-  llriliuli  CroMii  ('olonir<i  nnil  I'rotrotorktri. 
Thrsr  ri'iHirtx  iiri-  iiii  luliiiinilili'  •'Xuiii|ilc  of  llir  form  in  wliiili  IimiiI  uoviTiiiiiiMitH  hIioiiM  aiiiiiiBlly  prnrnt  thr 
fnct.i  of  lornl  frr(|iictii'y  of  iniiliiriiil  ili.triiitr*  nml  llii-  prrviiiliiiK  or  roiiti'iiipliitril  niitiiiinluriiil  mpa<um  for  thr 
iiiorr  rffcitivr  ronlrol  or  piooililr  rrjiiliriitioii  of  thr  <li«fii«f. 

II 


A  PLAN  FOR  ORGANIZED  PREVENTION 

important  problem.  In  tlie  furtherance  of  the  cooperative  effort  for  tht  M 
gradual  eradication  and  more  effective  control  of  malarial  diseases,  it 
is  particularly  desirable  that  the  local  incidence  of  the  disease  in  our 
island  possessions  should  be  made  the  subject  of  a  thorough  and  strictly 
scientific  inquiry.  The  malaria  problem  in  our  tropical  possessions 
should  be  considered  with  the  same  degree  of  thoroughness  and  complete 
ness  as  has,  for  illustration,  been  the  case  in  the  investigation  into  the 
causes  of  malaria  in  Bombay.  The  service  of  United  States  Marines  in 
certain  portions  of  Haiti,  San  Domingo,  Cuba  and  Nicaragua  need  only 
be  referred  to  as  a  further  practical  illustration  of  our  increasing  interest 
in  the  health  conditions  of  the  western  hemisphere. 

H.  Meteorological 

The  more  scientific  study  of  the  correlation  phenomena  of  malaria 
occurrence  and  meteorological  conditions  is  of  particular  urgency,  as 
best  illustrated  by  the  recent  contributions  of  O'Connell  on  Meteorology 
and  Malaria  to  the  Journal  of  Tropical  Medicine  and  Hygiene.  Instru- 
mental observations  require  to  be  made  with  more  accuracy  and  mi- 
nuteness, and  the  statistical  analysis  of  the  data  should  be  in  much  more 
detail  than  has  heretofore  been  the  case.* 

I.  Statistical  Considerations 

The  statistical  analysis  of  malaria  mortality  and  morbidity  data,  as 
well  as  the  correlation  of  malaria  with  other  diseases,  has  not  heretofore 
been  made  with  the  required  degree  of  thoroughness  and  attention  to 
detail.  As  an  excellent  illustration  of  the  method  more  or  less  to  be 
followed,  reference  may  be  made  to  the  statistical  analysis  of  data 
relating  to  an  epidemic  of  plague  in  three  districts  of  the  Punjab  by  M. 
Greenwood,  Jr.,  Statistician  to  the  Lister  Institute  of  Preventive  Medi- 
cine, also  to  the  report  by  S.  R.  Christophers,  contributed  to  the  Trans- 
actions of  the  Committee  for  the  Study  of  Malaria  in  India,  on  "Epi- 
demic Malaria  of  the  Punjab,  with  a  Note  on  a  Method  of  Predicting 
Epidemic  Years."  Accurate  and  conclusive  statistics  and  qualified 
methods  of  analysis  are  of  such  exceptional  importance  in  malaria  in- 
vestigations that  it  can  not  be  too  strongly  urged  that  this  aspect  of 
the  problem  of  the  gradual  and  ultimate  eradication  of  malaria  should 
receive  the  most  thoroughgoing  consideration,  including  a  reexamina- 
tion of  the  statistical  material  at  present  available  regarding  the  geo- 
graphical distribution  of  malarial  diseases  and  the  variation  of  incidence 
according  to  age,  sex,  race,  occupation,  etc. 

The  Report  of  an  Investigation  into  the  Causes  of  Malaria  in  Bombay 
and  the  Measurements  Necessary  for  Its  Control,  by  Chas.  A.  Bentley, 

*The  most  recent  contribution  by  Dr.  O'Connell  on  Meteorology  and  Malaria,  with  special  reference  to 
malarial  fevers,  in  England  appears  in  the  Journal  nf  Tropical  Medicine  and  Hygiene  for  December  15,  1916, 
in  which  the  atmospheric  conditions  of  Greenwich  in  August,  \iiiS,  are  subjected  to  a  minute  analysis,  since  at 
this  time  malarial  fevers  were  quite  common  in  the  southeast  of  England,  which  fact,  by  Dr.  O'Connell,  is  at- 
tributed to  the  atmospheric  conditions,  which  "were  such  as  would  cause  pyrexia  for  a  certain  number  of 
hours  bn  ten  different  days."     (For  more  extended  observations  on  meteorology,  see  pp.  14-16.) 

42 


;tc 


A  PLAN  FOR  ORGANIZED  PREVEMIOX 

d.  D.,  Bombay,  1911,  is  one  of  the  most  important  contributions  to 
he  practical  question  of  malaria  eradication  and  control.  The  report 
acludes  extended  observations  on  the  methods  of  measurements  of 
nalaria  in  Bombay  by  means  of  the  spleen  index,  blood  examination, 
nd  analysis  of  the  mortality  returns,  following  a  thoroughly  scientific 
iscussion  of  the  mosquitoes  of  Bombay.  The  conditions  which  in- 
uence  mortality  are  presented  in  a  brief  survey,  with  reference,  first, 
0  the  anophehne  factor  and,  second,  to  the  human  factor.  Reference 
i  also  made  to  overcrowding,  soil  disturbance,  migration,  education, 
tc.  The  prevention  of  malaria  in  Bombay  is  considered  with  reference 
o  the  history  of  past  efforts,  the  legal  aspects  of  mosquito  prevention, 
he  cost  of  mosquito  prevention  in  different  malarial  localities  through- 
ut  the  world  and  finally  the  cost  of  permanent  measures.  Following 
hese  observations  are  sections  on  the  obstacles  to  malaria  prevention, 
he  place  of  quinine  in  malaria  eradication,  and  special  reasons  which 
lake  it  imperative  "that  malaria  should  be  eradicated  from  Bombay." 
'he  report  is  illustrated  by  a  number  of  instructive  maps,  diagrams, 
lates  and  appendices  of  climatological  and  mortality  data.  No  local 
rea  in  the  United  States  has  been  investigated  and  reported  upon 
atli  a  similar  degree  of  thoroughness  and  scientific  as  well  as  practical 
onclusiveness. 

J.   Quinine  Prophylaxis 

On  account  of  the  highly  specialized  nature  of  the  quinine  question  in 
s  relation  to  malaria  eradication  and  control,  it  seems  advisable  that  this 
latter  should  be  subjected  to  a  thorough  reconsideration,  with  special 
sference  to  the  experience  which  has  been  had  during  the  construction 
eriod  of  the  PanamaCanal.  Of  special  value,  also,  is  the  practical  cxperi- 
nce  in  quinine  prophylaxis  in  the  island  of  Jamaica,  aside,  of  course, 
-om  the  well-known  methods  and  results  secured  in  Italy  and  in  certain 
actions  of  India,  particularly  Bombay. 

The  controversial  aspects  of  (luinino  pro])hylaxis  suggest  a  thor- 
ughly  impartial  reconsideration  of  all  the  available  facts.     According 

0  Dr.  Angus  McDonald,  in  an  address  before  the  Society  of  Tropical 
ledicine  and  Hygiene,  "(^iiiuine  has  its  position  in  relief  and  cure,  but 

1  sanitary  administration  it  has  none."  This  rather  far-reaching  coii- 
lusion  is  amplified  in  the  statement  that  "continuous  drugging  with 
uinine  may  prevent  attacks  of  malaria  in  anopheline  countries,  but 
tatislics  are  still  lacking  to  (jemonstrate  the  extent  to  which  the  taking 
f  this  drug  pn^vents  infection.  That  the  Iminaii  iiidividiia!  is  dctri- 
lentally  affected  by  the  continued  absorption  of  (luinine.  I)e  lie  atfccted 
vith  malaria  or  not,  there  can  l)c  little  doubt.  Whatever  arc  the  causes 
r  blackwater  fever,  there  seems  to  be  a  (consensus  of  opinion  that 
niriiiic  has  iiuicli  to  do  with  it,  p(>rhaps  more  to  «lo  with  it  than  malaria 
;i-."  This  conclusion  wjus  ojjposed  by  Dr.  ('.  K.  Hartford,  who.  with 
IM'cial  reference  to  Kuropean  missionaries  in  ('entral,  Ka.st  and  \Nest 
Vfrica,  points  out  "that  there  is  good  cause  for  adv(x-uting  the  u.sc  of  a 

43 


A  PLAN  FOR  ORGAMZED  PREVEXTfOX 

daily  dose  of  quinine  of  five  grains,  which  has  in  the  past  produced  mos 
important  results."  The  effect  of  quinine  on  the  malarial  parasite 
both  in  mosquito  and  in  man,  has  been  reported  upon  with  admirabl 
scientific  thoroughness  by  Dr.  Samuel  T.  Darling,  formerly  Chief  of  th 
Laboratory  of  the  Board  of  Health  of  the  Panama  Canal  Zone,  in  hi 
"Studies  in  Relation  to  Malaria." 

Of  interest  in  this  connection  is  the  following  extract  from  the  repor 
on  "Sanitation  in  Bengal  for  the  Year  1914,"  published  in  Calcutta 
1915:  "It  is  gratifying  to  observe  that  the  efforts  of  the  Malari; 
Committee  to  popularize  quinine  appear  to  be  meeting  with  success 
and  there  was  considerable  demand  for  quinine  in  the  'treatment'  forn 
in  which  it  is  now  sold.  The  sale  of  quinine  in  this  form  has  nearl} 
doubled  since  August,  1913.  Quinine  was  distributed  free  to  school 
children  in  the  Hooghly  district  through  the  agency  of  the  Educatior 
Department,  and  some  District  Boards  spent  considerable  sums  in  th(  ^r' 
purchase  of  cjuinine  for  free  distribution.  .  .  .  The  first  ste]  \'o 
towards  the  elimination  of  malaria  is  the  extension  of  the  use  of  quinine 
both  as  a  prophylactic  and  as  a  curative  medicine.  Much  good  will  nc 
doubt  result  from  measures  for  the  improvement  of  drainage  and  culti- 
vation, but  these  by  themselves  will  not  prevent  the  spread  of  malaria."* 


.on 


ie 


K.  Institutional  Treatment  of  Malaria 
On  account  of  the  fact  that  malaria  is  so  largely  a  rural  disease,  it  would 
seem  of  sufficient  importance  to  undertake  an  inquiry  into  the  rural 
hospital  facilities  for  proper  institutional  treatment,  as  opposed  to  super- 
ficial and  inadequate  treatment  at  the  patient's  home.  Since  malaria  is 
widely  spread  through  carriers  suffering  from  latent  malaria,  it  is 
of  the  first  importance  that  as  far  as  practicable  every  malaria 
patient  should  be  thoroughly  cured  of  the  disease,  to  the  extent,  at 
least,  of  no  malarial  parasites  being  ascertainable  in  the  peripheral  cir- 
culation. Since  the  guarding  of  malaria  patients  against  reinfection  is 
of  sufficient  importance  as  a  public-health  precaution,  the  institutional 
treatment  of  malaria  suggests  itself  as  decidedly  more  effective  than 
treatment  at  the  patient's  home.  Attention  may  be  directed  to  the 
excellent  sanitary  results  which  have  been  obtained  by  means  of  adequate 
rural  hospital  facilities  for  plantation  laborers  in  Hawaii  and  in  con- 
nection with  the  plantations,  etc.,  of  the  United  Fruit  Company,  in 
Cuba,  Guatemala,  Costa  Rica,  Colombia,  etc.  f 

*Some  exceptionally  useful  observations  on  Quinine  Propaganda  in  Bengal,  by  C  A.  Bentley,  and  the 
Quininisation  of  School  Children  in  the  United  Provinces,  by  Maj.  F.  D.  Graham,  are  contained  in  the  Pro- 
ceedings of  the  Third  Meeting  of  the  General  Malaria  Committee  held  at  Madras,  in  1912.  See,  also,  in  this 
connection  Chapter  iv  on  the  Treatment  of  Malarial  Fevers,  with  special  reference  to  the  use  of  quinine  in 
Malarial  Fevers,  by  Chas.  F.  Craig,  M.  U.,  New  York,  1909.,  and  Chapter  viii  on  Treatment  of  Malaria,  in 
Deaderick  and  Thompson's  "Endemic  Diseases  of  the  Southern  States,"  Philadelphia,  1916. 

tThe  excellent  results  of  adequate  hospital  facilities  are  described  by  Malcolm  Watson  in  his  treatise  on 
"Rural  Sanitation  in  the  Tropics,"  with  special  reference  to  the  plantation  system  of  the  Dutch  Tobacco 
Company,  of  the  island  of  Sumatra.  Between  1901  and  1911  the  general  hospital  death  rate  was  reduced  from 
11.4  per  cent,  to  2.6  per  cent.,  and  the  general  death  rate  of  the  entire  labor  force  from  50.0  to  12.0  per  1,000. 
The  principal  hospital  is  located  at  Medan  and  contains  about  600  beds.  During  1910-1911  the  admission 
rate  for  malaria  was  only  2.4  per  cent. 

44 


II 


A  PLAX  FOR  ORGAMZKD  FRFA'EXTIOX 

'^  L.  Historical  Research 

The  appearance  and  disappearance  of  malaria  in  different  sections  of 

''<  16  world  during  more  or  less  prolonged  periods  of  time  have  an  important 

'earing  upon  the  better  understanding  of  the  conditions  and  circum- 

'ances  which  govern  the  control  and  ultimate  eradication  of  malarial 

isease  in  the  western  hemisphere.  The  early  history  of  malaria  in  Greece 

'^  nd  Italy  and  its  relation  to  the  social  and  economic  progress  of  the  pop- 

lations  concerned  and  its  possible  causative  influence  on  the  decay  of 

^  ertain  nations  of  antiquity  forcibly  suggest  the  value  of  pertinent  his- 

orical  illustrations  in  support  of  modern  efforts  to  eradicate  malaria 

om  vast  portions  of  the  western  hemisphere   which   are   at  present 

ither  more  or  less  uninhabitable  on  account  of  malarial  disease  or  which 

ave  been  materially  hindered  in  their  economic  progress,  as  best  illus- 

rated  by  the  Yazoo  Delta  of  Mississippi,  a  large  portion  of  the  states  of 

"^irkansas  and  Louisiana  and  contiguous  areas  in  the  coastal  plain  of 

North  and  South  Carolina  and  Georgia.* 

M.  Zoological 

The  practical  use  of  natural  enemies  of  mosquitoes  suggests  a  vast 
eld  of  qualified  scientific  research  of  a  high  order  of  importance.  The 
ooperation  of  the  United  States  Fish  Commission  might  be  enlisted  in 
n  effort  to  ascertain  how  far  certain  fishes  have  been  found  useful  in  the 
Vest  Indies  and  Hawaii  in  local  efforts  at  mosquito  eradication,  and 
vhether  such  methods  of  eradication  might  advantageously  be  intro- 
luced  into  the  United  States.  Much  the  same  conclusion  applies  to  a 
urther  inquiry  into  the  efficiency  and  practical  usefulness  of  alleged 
leterrent  trees  and  plants,  such  as  the  eucalyi)tus,  the  papia,  the  china- 
)erry  trees,  water-plants,  etc.  The  United  States  Department  of  Agri- 
ulture,  through  its  numerous  scientific  subdivisions,  in  cooj)eration  with 
he  Natif)nal  Museum  and  the  American  Museum  of  Natural  History, 
IS  well  as  other  organized  scientific  bodies,  should  be  in  a  position  to 
cndcr  substantial  aid  in  this  direction.! 

'The  most  useful  source  o(  information  on  the  early  histor>'  of  maluriul  disenses  is  llie  "HaniUmok  of  Gro- 

raphirnl  and  Historical  PathoioK.v,"  by  Ur.  AuKust  Hirsch,  translated  t>y  Charles  C'reif{hton.  lAjndon,  189S. 
InlereslinR  historical  data  and  early  slalisliis  are  iiiclii<|ed  in  the  treatise  on  Malaria  liy  Prof.  Dr.  Angelo 

'elli,  <d  (ierinan  Ed.,  Berlin,  IIM.S.  A  curious  and  practically  unknown  coiilrilmtion  to  the  early  hi.story  of 
tialaria  is  a  work    entitled  "Dello  Stato  Kisico  del  Suolo  de  Kouia.  Meinoria   per  servile  d'illuslrazione  alia 

'arta  (leognostica  di  quritn  cilta.  Di.  (i.  Hro<chi.  Konin,  1H<0,  reviewed  in  the  Edinburgh  R*riev,  Frbruary, 

SH.     Also,  "Travels  of  Intermittent  Fever,"  in  Khode  Islan<t  Annual  Health  Heport,  IHH6. 

tin  an  admirable  address  on  "Insect  Home  Diseases  in  l'an-.\merica,"  by  Dr.  Juan  (iuiteras.  Director  of 

leallh  of  Cuba,  and  professor  of  K<°i<cral  pathology  ami  tropical  diseases  in  the  Cniversity  of  Havana,  read 
lefore  the  Second  Pan-.Vmeriian  Scienlilii'  ConKress,  an  extended  ri-ferencc  is  made  to  the  early  otiservalionsof 

>r.  Josiah  C.  Nutt,  of  Mobile,  .Ma.,  on  yellow  fever,  aa  contrasted  with  bilious  fever,  and  rea.sons  for  believiiiK 
t  a  disease  lui  generis,  its  mode  of  propagation,  remote  cause,  probable  insect  or  animalcular  origin,  etc.,  which 
ippeared  in  the  .V'eir  OrUana  Medtcul  and  Surgical  Journal  for  March,  IH'iH.  This  paper  for  the  lirst  time 
irescnied  the  insect  hypothesis  in  ilisease  transmissiim,  w  liich  has  .since  heconie  universnllv  accepted  ou  the 
lasis  of  the  subse<|uent  precise  ascertainment  of  the  true  cause  of  yellow  fever  by  the  I  nited  States  .\rniy 
Vfedical  Hoard,  consistiug  of  Drs.  Heed,  Luxear,  (,'arroll  and  .VKramonte,  who,  however,  in  a  large  measure 
iwe  the  results  of  their  immortal  discovery  to  the  previous  researches  of  Dr.  Carlos  J.  Finlay,  of  Havana,  who 

ince  IHHI  had  been  investigating  and  reporting  upon  the  possible  relation  of  the  mosi|uilo  to  yellow  fever, and 
if  Dr.  H.  It.  Carter,  of  the  L'nileil  Slates  Public  Health  Service,  who,  some  years  earlier,  had  made  public  bis 

poi'h-making  observations  upon  the  intrinsic  incubation  of  >  ellow  fever.  As  well  said  by  Major-deneral 
'iorgas.  in  his  work  on  Sanitation  in  Panama.  "The  report  of  Carter  turned  out  to  be  pure  gold  ami  was  one  of 

\5 


A  PLAN  FOR  ORGANIZED  PREVENTION 

The  practical  use  of  natural  enemies  of  mosquitoes  is  discussed  at 
some  length  in  Volume  I  of  the  treatise  on  "The  Mosquitoes  of  North 
and  Central  Ameriea  and  the  West  Indies,"  by  Howard,  Dyar  and  Knab, 
published  by  the  Carnegie  Institution  in  lOlS.  A  reference  of  special 
interest  is  to  the  introduction  of  the  so-called  "millions,"  which  are  a 
minnow  of  very  small  size  (the  full-grown  females  measuring  only  about 
one  and  one-half  inches  in  length,  while  the  male  is  much  smaller),  from 
the  island  of  Barbados,  which  is  free  from  malaria,  into  the  more  or  less 
permanent  waters  of  the  island  of  Antigua,  which  is  considerably  afHicted 
with  the  disease.  It  is  said  that  many  planters  and  others  commented 
on  the  evident  abatement  of  the  mosquito  nuisance  in  numerous  localities. 
A  limited  test  in  the  Panama  Canal  Zone  was  apparently  productive  of 
satisfactory  results,  for  Major-General  Gorgas  is  quoted  in  a  statement 
to  the  effect  that  he  approved  of  the  use  of  "millions"  wherever  it  could 
be  done.  Malcolm  Watson,  in  his  treatise  on  "Rural  Sanitation  in  the 
Tropics,"  reporting  upon  conditions  in  Barbados,  contradicts  the  general 
theory  that  the  absence  of  malaria  from  the  island  was  attributable  to  the 
universal  presence  of  "millions,"  holding  that  Barbados  is  free  from 
malaria  "because  of  the  relative  absence  of  breeding-places,"  due  to  the 
exceedingly  favorable  conditions  of  natural  subsoil  drainage.  In  the 
treatise  on  "The  ^Mosquitoes  of  North  and  Central  America  and  the 
West  Indies,"  by  Howard,  Dyar  and  Knab,  extended  consideration  is 
also  given  to  alleged  deterrent  trees  and  plants,  chiefly  the  eucalyptus, 
ricinus  and  papaya,  china-berry  trees,  peat  and  water-plants.  The 
whole  question  of  natural  enemies  is  admirably  summarized  by  Mr. 
John  B.  Smith,  Entomologist  of  the  New  Jersey  State  Agricultural  Ex- 
periment Station,  in  his  report  upon  the  mosquitoes  occurring  within 
that  state,  their  habits,  life  history,  etc. 

XIV.    General   Conclusions  and   Observations  on  the  Economic 
Importance  of  Malarial  Diseases 

The  economic  losses  resulting  from  malaria  are  enormous,  but  exceed- 
ingly difficult  of  precise  ascertainment.  In  1903  Prof.  Glen  W.  Herrick 
contributed  an  article  to  the  Popular  Science  Monthly  on  The  Relation 
of  Malaria  to  Agricultural  and  Other  Industries  in  the  South,  which  in 
1909  was  followed  by  a  bulletin  of  the  Bureau  of  Entomology  on  The 
Economic  Loss  to  the  People  of  the  United  States  Through  Insects 
That  Carry  Disease,  by  L.  O.  Howard.  The  same  distinguished  author- 
ity gave  more  extended  consideration  to  the  subject  in  the  first  volume 
of  the  collective  investigation  on  "The  Mosquitoes  of  North  and  Central 
America  and  the  West  Indies,"  published  by  the  Carnegie  Institution  in 

the  great  steps  in  establishing  the  true  method  of  transmission  of  yellow  fever."  The  sanitary  achievements  in 
Havana,  past  and  present,  arc  primarily  the  work  of  Major-Ooncral  W.  C.  Gorgas  and  Dr.  .luan  Guileras.  It 
is  entirely  due,  however,  to  the  cnli^chtened  attitude  of  the  Cuban  government  that  the  theories  of  insect-borne 
diseases  have  been  rigidly  applied  and  that  both  yellow  fever  and  malaria  have  become  practically  extinct  in 
an  island  which,  in  former  years,  was  often  disastrously  afflicted  by  both  of  these  diseases.  Reference  may 
also  be  made  here  to  an  interesting  contribution  on  the  mosquitoes  of  the  Republic  of  Cuba,  by  Dr.  J.  H. 
Pazos,  of  Havana. 

46 


A  PLAN  FOR  ORGANIZED  PREVENTION 

1912.  Prof.  Howard  at  the  time  estimated  the  malaria  death  rate  for  the 
entire  United  States  at  15  per  100,000  of  population,  equivalent  to  an 
annual  loss  of  life  of  12,000.  He  points  out  that  this  is  but  an  inadequate 
indication  of  the  economic  loss  in  health  and  physical  strength,  for  "A 
man  may  suffer  from  malaria  throughout  the  greater  part  of  his  life  and 
his  productive  capacity  may  be  reduced  from  fifty  to  seventy-five  per 
cent,  and  yet  ultimately  he  may  die  from  some  entirely  different  im- 
mediate cause."  Assuming,  however,  a  mortality  of  12,000  per  annum, 
Prof.  Howard  estimates  the  number  of  cases  of  malaria  at  1,500,000,  of 
which  it  is  safe  to  assume  the  larger  proportion  occur  in  adult  life. 

More  recent  discussions  of  the  economic  aspects  of  malaria,  with 
special  reference  to  agriculture,  are  by  W.  D.  Hunter  and  D.  L.  Van 
Dine,  of  the  United  States  Bureau  of  Entomology,  concluding  with 
a  paper  on  the  Relation  of  Malaria  to  Crop  Production,  by  D.  L.  Van 
Dine,  published  in  the  Scientific  Monthly,  November,  1916.  It  is  stated 
that  Howard  in  1909  estimated  the  annual  economic  loss  on  account  of 
malaria  throughout  the  United  States  at  not  less  than  $100,000,000, 
and  subsequent  investigations,  including  a  careful  analysis  of  actual 
plantation-labor  experience,  indicate  that  this  estimate  is  probably  con- 
servative. William  B.  Hermes,  in  his  treatise  on  malaria,  with  special 
reference  to  California,  has  estimated  the  economic  loss  on  account  of 
malaria  in  that  state  at  nearly  $3,000,000.  The  same  authority  quotes 
the  opinion  of  the  National  Conservation  Commission  that  eighty  per 
cent,  of  the  malaria  in  this  country  could  be  prevented.  Dr.  Graham  A. 
Henson,  in  his  work  on  malaria,  published  in  1913,  observes  with  reference 
to  the  economic  loss  that  on  the  basis  of  such  data  as  were  available  and 
the  knowledge"  of  what  has  been  accomplished  wherever  a  consistent  cam- 
paign has  been  instituted  against  malaria  infection  it  would  appear  that 
the  time  can  not  be  far  distant  when  the  importance  of  the  eradication 
of  the  disease  will  be  taken  up  seriously  by  legislative  and  administra- 
tive bodies."  This  conclusion  applies  to  every  country  in  which  malaria 
is  known  to  prevail  to  a  more  or  less  serious  degree;  but  to  no  section 
of  the  world  as  much  as  to  the  Southern  States  and  the  malarious  regions 
of  the  Central  and  South  American  Republics.  A  material  reduction 
in  the  malaria  death  rate  can  not  fail  to  bring  about  a  lesser  prevalence 
of  other  serious  diseases,  for  wherever  malaria  prevails  extensively  the 
general  death  rate  is  high,  even  though  the  disease  itself  may  not  be  a 
predominant  cause.  The  average  death  rate,  for  illustration,  of  Mauritius, 
which  is  intensely  malarious,  during  the  three  years  ending  with  1906 
was  37.6  per  1,000  of  po[)ulation,  whereas  the  corresponding  average 
rate  for  the  nearby  Seychelles  Islands  was  only  15.9.  The  Seychelles 
are  mountainous  and  practically  free  from  anopheles  mosquitoes. 

The  malaria  death  rate  is  not,  of  course,  a  sufficient  basis  for  an 
estimate  of  the  economic  loss  resulting  largely  in  c()nse((Uonce  of  pro- 
longed illness  and  diminished  physical  ofHciency.  The  economic  value  of 
human  life  also  varies  considerably  according  to  age,  race  and  local  labor 

47 


A  PLAX  FOR  ORGANIZED  PREVENTIOX 

conditions,  so  much  so  that  practically  any  and  every  estimate  is  largely 
a  matter  of  pure  conjecture.  Estimating  the  present  malaria  mortality 
of  the  United  States  (for  1916)  on  the  basis  of  revised  data  brought  down 
to  date  for  the  Southern  registration  states  and  cities  at  15, 000  deaths 
and  assuming  a  fatality  rate  of  1.5  per  cent.,  the  approximate  number 
of  cases  of  malaria  in  this  country  per  annum  can  not  fall  below  1,000,000. 
Possibly  the  actual  number  is  materially  in  excess  of  this  assumption. 
The  cause  of  malaria  eradication,  therefore,  rests  upon  sound  economic 
as  well  as  self-evident  humane  considerations,  leaving  no  escape  from 
the  final  conclusion  that  the  entire  subject  most  urgently  demands  the 
qualified  and  intelligent  coordination  of  all  existing  governmental 
agencies  and  related  health-conserving  activities,  on  the  one  hand,  and 
a  broad-minded  public  policy,  on  the  other,  with  special  reference, 
however,  to  expenditures  in  behalf  of  local  antimalarial  measures  on 
the  part  of  the  general  public.  For  economic  reasons  alone  the 
effort  would  be  worth  while,  since  the  economic  results  of  effective 
antimalarial  measures  are  a  foregone  conclusion.  The  attainment  of 
more  or  less  complete  malaria  eradication  throughout  the  country  will 
require  many  years  of  intelligent,  coordinated  effort,  sustained  by 
liberal  governmental  appropriations,  than  which  no  nation  in  the 
world  could  make  a  better  investment  for  the  good  of  its  citizenship 
than  the  United  States.  The  fundamental  principle  of  permanent 
success  in  malaria  eradication  is  the  intelligent  and  effective  coordi- 
nation of  all  the  measures  and  means,  agencies  and  organizations,  that 
can  be  utilized  in  the  warfare  against  this  most  insidious  foe  of  mankind. 
A  perfect  working  plan,  however,  can  only  be  the  result  of  extended 
experience  and  mature  consideration  on  the  part  of  many  men  and  minds 
thoroughly  familiar  with  the  facts  and  conditions  of  local  experience 
resulting  either  in  failure  or  success.  It  is  hoped,  therefore,  that  the  fore- 
going considerations  and  suggestions  may  prove  of  practical  value  in  the 
ultimate  attainment  of  our  national  ideal  of  the  most  perfect  health  and 
the  longest  attainable  duration  of  life  throughout  the  entire  United  States, 
w^hich  is  far  from  being  the  case  at  the  present  time.  As  has  well 
been  said  by  the  late  William  Edward  Hartpole  Lecky,  "How  different 
would  have  been  the  condition  of  the  world,  and  how  far  greater  would 
have  been  the  popularity  of  strong  monarchy  if  at  the  time  when  such 
a  form  of  government  generally  prevailed  rulers  had  had  the  intelligence 
to  put  before  them  the  improvement  of  the  health  and  the  prolongation 
of  the  lives  of  their  subjects  as  the  main  object  of  their  policy  rather 
than  military  glory  or  the  acquisition  of  territory  or  mere  ostentatious 
and  selfish  display!"  This  observation  holds  even  more  true  for  a 
republic,  in  which  responsibility  for  governmental  policy  rests  primarily 
upon  the  people  themselves.  In  its  final  analysis,  therefore,  the  prob- 
lem of  malaria  eradication  is  one  of  public  education  and  an  aroused 
public  conscience  and  understanding  regarding  the  largely  unnecessary 
loss  of  life  and  health  in  consequence  of  the  continued  and  unnecessary 

48 


A   FLAX  FOR  ORdAMZKn  riHAIXIKKX 

prevalence  of  malarial  diseases.  In  proportion  a.s  the  piil)lic  knowledge 
of  the  measures  and  means  whereby  malaria  can  l>e  eradicated  is  j)er- 
fected  will  the  elimination  of  this  disease  from,  at  least,  the  Iniled  States 
be  attained  within  a  measurable  period  of  time.* 

•Annoni?  the  sueeestive  recent  indications  of  an  aroused  interest  in  ni  .'   -  ...o 

to  the  Journal  of  Tropical  Medicine  and  Hyjiene,  by  Or.  W.  M.  Mcli  -1. 

.lohn,    .\nlipua,  recommendinK  the  institution  of  rural  anti-ni»s<|uitu  ni'  li, 

1916).      Dr.  McDonald  suggests  the  estatjiishment  of  an  ex[>erimental  aria  fu-  •  <4 

the  efficacy  of  various  anti-mosquito  measures  on  the  hiisic  primiple  of  (iovrrnin  Ird 

as  bearing  the  same  relation  to  the  prevention  of  dis<-a»i-  among  Ulwrrri  a«  ;:.      \.  !al 

Station  does  to  the  prevention  of  disease  among  cane*.     The  prinnpal  obj<-<ls  of  i  .  %n 

explained  to  be  "(a)  to  provide  practical  knowledge  of  the  working  of  vfiriiiii«  -inti-i-;  to 

dclcrniine  which  of  these  measures  in  practice  combine  a  maximurj.  to 

determine  whether  the  cost  of  the  more  exp»-n.sive  measures  it,  in  r   .  ;  Itjr 

the  results  of  these  measures;  (d)  to  determine  whether  adoption  "'  .  .•    ta 

prove  of  any  avail  even  if  we  are  deterred  b.v  financial  limitations  frum  uarryiag  out  Lbc  au>rv  cspEoairr  oir**- 
ures." 

The  several  more  important  rural  antimalarial  measures  arc  slat>-il  in  '"  ■         •  '  .  «« 

follows:      "(1)    Utilizittion  of  the  natural  enemies  of  the  nios<|uiti>,  such  .i» 

fb)  Oiling  of  pools,  ditches,  and  stream*,      (r)    Drainage.      i<i)  (iratiing   i  r.xtA. 

otherwise  be  effectually  treated." 

The  article  concludes  with  the  statement  that  "the  relative  cost  of  HHcienc)*  ol  tbear  mrmaurra  raa  oaljr 
be  ascertained  by  practical  experimental  work  io  the  field,  but  in  view  of  the  l)enefitj  w'-  '■  -  '  '  ---  i-  ■  >  tb« 
individual,  to  the  landowners,  to  the  (iovernment,  and  to  the  community  generally  b-.  .rn 

the  reduction  of  malarial  and  filarial  disease  in  the  colony,  1  would  miMt  rrs[>ct-lftillv  •  .Ii.- 

money  could  not  be  better  spent  than  in  the  establishment  of  an  ex|xTi  ■   <rf 

antimalarial  measures  having  in  view   the  eventual  institution  of  an  a'.  il»«- 

island.     I  venture  to  represent  further  that  the  present  moment,  when  th<- ,        _  .  .  ._      'er* 

has  been  attracted  to  the  economic  value  of  erailication  of  liisease  by  the  work  done  in  the  .Vnkylastooiiaaa 
Campaign,  is  an  opportune  time  for  enlisting  the  cooperation  of  the  public  in  antimalarial  work." 

Of  special  practical  educational  value  are  the  illustrated  placards  iHued  by  the  Philippinr  llrallh  Srnri«» 
ill  the  native  languages,  showing  the  life  history  of  the  mosquito  and  the  method  of  Irantmiuion  of  malarial 
infection,  used  in  the  biirrio-i  of  .Mindoro. 


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PART  III 

SOME  ESSENTIAL  STATISTICAL  CONSIDERATIONS 

An  effective  and  far-reaching  practical  plan  of  malaria  eradication 
must  obviously  rest  upon  a  well-considered  statistical  basis  of  evidence 
derived  from  trustworthy  official  and  other  sources.  The  selection  of 
unit  areas  for  active  antimalarial  measures  is  in  its  initial  considerations 
largely  a  statistical  problem,  and  the  results  of  subsequent  experience, 
or  the  efficiency  or  failure  of  particular  methods  and  means,  are  often 
determinable  by  statistical  methods  alone.  Many  important  aspects  of 
the  problem  of  malaria  prophylaxis  require  the  ascertainment  of  ele- 
mentary conditions  in  conformity  to  qualified  methods  of  statistical  and 
even  mathematical  analysis.  The  best  illustration  of  this  point  of  view 
is  the  elaborate  presentation  of  evidence  on  the  prevention  of  malaria 
in  the  collective  treatise  on  the  subject  by  Sir  Ronald  Ross,  which  includes 
contributions  by  Prof.  L.  O.  Howard,  Major-General  W.  C.  Gorgas, 
J,  A.  LePrince,  Prof.  A.  Celli,  etc.  International  statistics  of  malaria 
frequency  are,  unfortunately,  not  thoroughly  trustworthy,  although  in  a 
general  way  they  may  be  relied  upon  as  approximately  conclusive. 
Since  malaria  is  largely  a  disease  of  rural  sections,  it  is  really  deplor- 
able that  the  larger  portion  of  the  rural  area  of  the  Southern  States 
in  which  the  disease  is  known  to  prevail  to  a  more  or  less  serious  degree 
should  not  be  wnthin  the  registration  area  as  defined  and  accepted  by  the 
Division  of  Vital  Statistics  of  the  United  States  Census. 

In  view  of  the  fact  that  the  mortality  from  malaria  is  not  a  true  index 
of  the  relative  seriousness  of  malaria  frequency  as  a  disease,  it  is  even 
more  regrettable  that  malaria  morbidity  data  for  many  important 
infected  areas  should  not  be  obtainable  otherwise  than  by  means 
of  institutional  returns,  which,  of  course,  may  or  may  not  be  con- 
clusive. Since  the  fatality  rate  in  malaria  varies  considerably  ac- 
cording to  the  type  or  form  of  malarial  infection,  it  is  self-evident 
that  the  extent  of  morbidity  is  not  always  safely  ascertainable,  with 
even  approximate  accuracy,  from  mortality  returns  which  fail  to  differ- 
entiate the  principal  types  of  malaria,  i)articularly  tiie  tertian,  the 
estivoautumnal  and  the  quartan  infection.  In  some  sections  one  type 
prevails,  to  the  ])ractical  exclusion  of  the  others,  with  a  high  morbidity 
and  a  low  mortality  rate,  while  in  others  the  morbidity  rate  may  be  less, 
but  the  mortality  rate  much  higher.  For  the  United  States  registration 
area  during  the  period  1010-1914  the  average  mortality  from  malaria  was 
2.6  per  100,000  of  population,  which  in  proportion  to  the  mortality  from 
other  causes  is   obviously  insignificant.     The   returns  for  the   United 

51 


STATISTICAL  CONSIDERATIONS 

States  registration  area,  unfortunately,  are  exclusive  of  the  sections 
of  the  Southern  States  where  the  disease  is  known  to  prevail  to  a 
more  or  less  serious  degree.  Thus,  for  illustration,  when  the  returns 
for  the  state  of  Kentucky  and  the  registration  cities  of  Tennessee  and 
Alabama  are  combined,  the  resulting  average  malaria  mortality  rate  is  15.0 
per  100,000  of  population.  For  the  cities  of  Tennessee  alone,  however, 
the  rate  is  40.2.  No  general  malaria  mortality  returns  for  states  and 
large  areas  can,  therefore,  be  considered  conclusive,  and  in  all  cases  a  cor- 
rection is  necessary  for  the  possible  impairment  of  the  data  on  account 
of  the  inclusion  of  institutional  returns.  Malaria  is  nearly  always  a  local 
'problem,  and  the  rate  of  incidence  is  governed  by  local  conditions.  Even 
in  the  Pacific  Coast  States,  where  the  disease  is  relatively  rare  and, 
as  a  general  rule,  not  of  serious  importance,  particular  localities  may 
be  and  are  subject  to  a  comparatively  high  rate  of  incidence  of  malarial 
infection,  which  is  obscured  in  the  low  general  average  mortality  or  mor- 
bidity for  the  state  at  large.  In  North  Carolina,  including  only  munici- 
palities with  at  least  1,000  population,  the  malaria  mortality  rate  is  26 
per  100,000  of  population;  in  the  city  of  Charleston,  S.  C,  during  the 
period  1910-1914,  it  was  30.9;  in  the  principal  cities  of  Georgia,  27.6; 
and  in  the  principal  cities  of  Florida,  27.7.  These  rates  are  fairly 
conclusive,  but  the  populations  directly  concerned  suffer  to  a  much 
larger  extent  than  is  indicated  by  average  returns.* 

Probably  the  most  intensely  malarial  sections  of  the  United  States  are 
the  Yazoo  Delta  counties  of  Mississippi,  the  river  counties  of  Tennessee, 
the  river  counties  of  southeastern  Missouri  and  the  river  counties  of 
Arkansas  and  northern  Louisiana.  It  is  only,  however,  for  the  river 
counties  of  southeastern  Missouri  that  approximately  trustworthy  data 
are  available,  and  these  indicate  an  extraordinary  degree  of  malarial  in- 
tensity. Combining  the  returns  for  seven  counties  of  Missouri,  it  ap- 
pears that  the  average  rate  of  mortality  from  malaria  for  the  four  years 
ending  with  1914  was  168.8  per  100,000  of  population  and  that  the  rate 
was  as  high  as  296.7  for  Dunklin  County,  which  as  far  as  known  is 
probably  one  of  the  most  intensely  malarial  sections  as  regards  the  fatal 
form  of  malarial  fever  in  this  country.  Possibly  certain  counties  of 
Arkansas  and  Mississippi,  however,  are  even  more  seriously  affected,  but 
no  official  mortality  returns  regarding  them  are  at  present  available. 
It  is  quite  probable  that  the  local  intensity  may  be  decidedly 
higher,  but  thus  far,  excepting  to  the  extent  of  the  active  efforts  on 

*Some  exceptionally  valuable  local  investigations  have  been  made  by  the  United  States  Public  Health 
Service  in  the  direction  of  ascertaining  the  precise  degree  of  intensity  in  the  geographical  area.  Among  other 
publications  of  practical  value  reference  may  be  made  to  reprint  No.  160,  Malarial  Fevers  in  Arkansas;  reprint 
No.  m.  Malarial  Fevers  in  South  Carolina,  Georgia  and  Florida;  reprint  No.  186,  Malarial  Fevers  in  Ala- 
bama; and  reprint  No.  193,  Malarial  Fevers  in  Mississippi.  Reprint  No.  277  has  a  general  review  of  malaria 
morbidity  by  states  and  types  of  infection,  with  a  due  regard  to  race  by  counties  and  seasons  of  the  year. 
This  investigation,  limited  to  eight  Southern  states,  includes  81,085  cases  of  malaria  reported,  but  only  on  the 
basis  of  13  per  cent,  of  returned  replies  to  the  cards  mailed  to  practising  physicians  in  the  states  referred  to. 
The  approximate  morbidity  rate,  as  estimated  by  this  investigation,  made  chiefly  under  the  direction  of  the 
late  R.  H.  von  Ezdorf,  was  5.36  per  1,000.  If  calculated  on  the  basis  of  complete  returns,  the  true  malaria 
morbidity  rate  in  the  eight  states  combined  would  be  4  per  cent.,  equivalent  to  600,000  affected  persons  for 
the  year. 

52 


S  TA  TIS  TICAL  CONSIDER  A  TIOXS 

the  part  of  the  International  Health  Commission  of  the  Rockefeller 
Foundation,  a  thoroughly  qualified  investigation  has  not  been  made. 
The  practical  importance  of  malaria  frequency  and  the  urgency  of  its 
eradication  in  southeastern  Missouri  are  best  illustrated  by  the  fact 
that  the  rate  for  Dunklin  County  of  296.7  per  100,000  is  in  excess  of  the 
corresponding  rate  for  Trinidad  and  Tobago  of  218.9;  and  almost  the 
same  as  the  rate  for  Venezuela,  which  is  .'50.3. (J.  Even  the  city  of  Free- 
town, Sierra  Leone,  on  the  West  Coast  of  Africa,  with  its  notoriously 
high  general  death  rate,  has  a  malaria  rate  of  only  251.8,  in  contrast  to  a 
rate  of  296.7  for  Dunklin  County.  Granting  that  the  true  intensity  of 
malaria  frequency  can  not  be  accurately  determined  by  means  of  the 
death  rate  as  ascertainable  uj)on  the  basis  of  more  or  less  untrustworthy 
death  certificates  from  rural  districts,  it  is,  nevertheless,  an  entirely  safe 
conclusion  that  there  are  still  sections  in  the  United  States  which  are  so 
seriously  afflicterl  with  malarial  disease  as  to  challenge  com[)arison  with 
some  of  the  most  unhealthy  portions  of  other  countries  cfiually  afllicted 
with  malarial  disease.* 

Subject  to  the  caution  that  all  international  malaria  mortality  statis- 
tics require  to  be  accej)ted  and  used  with  extreme  care,  the  available 
official  data  have  been  l)ri('fly  summarized  in  Table  I  of  the  .Vppendix. 
According  to  this  tal)Ie  the  highest  death  rate  from  malaria  at  the 
present  time  (that  is,  the  period  ending  generally  with  1914  or  1915) 
prevails  in  the  i.sland  of  Mauritius,  where  during  1910-1914  it  reached  the 
extreme  figure  of  1176.9  per  100,000  of  jxjpulation.  Among  other 
conspicuous  illustrations  of  an  excessive  incidence  of  nudaria  mention 
may  be  made  of  Nicaragua,  where  during  1908-1911  the  mortality  rate 
reached  727,5,  British  Honduras,  where  during  1914-1915  it  reached 
589.7,  British  Cuiana,  where  during  1911-1915  it  reached  421.0,  the  city 
of  (iuayaquil,  Ecuador,  where  the  rate  is  424.0,  aiid  finally  the  IMiiiip- 
pine  Islands,  where  during  the  [)eriod  1909-191.S,  regardless  of  active 
efforts  at  eradication,  the  rate  still  maintained  the  high  level  of  397,5. 
The  extraordinary  significance  of  these  figures  may  best  be  realized 
when  it  is  stated  that  for  Italy,  which,  in  its  southern  portion  at 
least,  is  generally  considcreil  intensely  mahiri;d,  the  mortahty  during 
1909-1913  was  only  10.0  per  100,000,  and  even  among  the  Euroinrun 
[)opuIation  of  Algeria,  which  formerly  w.is  (onsideretl  (>xtremely  un- 
healfhful,  in   fact,   the  grave  of   Europeans  sellliMg  in   tin*   interior  or 

♦Mortality  from   Muluria  in  Seven  Coiinlif*  of  Soiilhrrn   MiMniiri,   lOIUIOII 

I>*alk>  lUt*  |Mt 

ToUl  Irani  IW.uuo 

Counly  HnliuUlInn  MkUrla  Tu^lMlnn 

Dunklin l.lO.TBfl  .n«M  tfM  7 

Butirr 80,710  154  178  7 

Proiijiot 80..i07  141  I7«  • 

Stodilanl                          IM.OO.'.  178  l4A.t 

Nrw.M«<lriil 80.l»4.i  1*1  IS9  t 

Scolt »0.00<  »*  M  3 

MiMiuippi «l,«04  S8  04   I 

ScvenCoHnlir. 6M,S«4  I.W4  lOK  ■ 

AS 


S  TA  TIS  TICAL  CONSIDER  A  TIONS 

engaged  in  colonization  work,  the  malaria  mortality  was  only  47.6  during 
the  five  years  ending  with  1912.* 

It  is  realized,  as  said  before,  that  these  statistics  are  not  conclusive. 
They  have  reference  chiefly  to  large  areas,  regardless  of  the  fact  that 
malaria  is  almost  invariably  a  strictly  localized  health  problem.  It  has 
seemed  best,  therefore,  for  the  purpose  of  a  public  discussion  to  draw 
particular  attention  to  the  malaria  death  rate  of  large  cities,  and,  granting 
that  the  statistics  are  occasionally  impaired  by  institutional  admissions 
from  the  surrounding  country,  the  data  are  in  all  probability,  at  least 
for  general  purposes,  more  useful  and  conclusive  than  the  data  for 
countries  at  large.  The  malaria  mortality  statistics  of  fourteen 
representative  cities  throughout  the  world  have  been  brought  to- 
gether in  Table  II  of  the  Appendix,  for  the  purpose  of  emphasizing  the 
wide  range  in  malarial  incidence  in  sections  where  the  disease  has 
been  endemic  for  many  years  and  the  considerable  actual  and  relative 
reduction  in  the  malaria  death  rate  in  localities  where  the  disease  has 
been  brought  gradually,  if  not  as  yet  entirely,  under  effective  control,  f 

Among  other  astonishing  illustrations  of  the  truly  remarkable  progress 
achieved  in  consequence  of  the  furtherance  of  antimalarial  measures 
it  is  shown,  by  comparing  the  malaria  death  rate  of  Havana,  Cuba, 
for  1900-1904,  when  it  was  49.0  per  100,000  of  population,  with  the 
corresponding  death  rate  for  1910-1914,  when  it  was  2.4  per  100,000, 
or  practically  negligible.  The  reduction  achieved  during  the  period 
under  consideration  was  equivalent  to  95.1  per  cent.  In  St.  Thomas, 
Danish  West  Indies,  there  has  been  a  corresponding  reduction  in  the 
mortality  from  malaria  during  the  same  period  of  88.8  per  cent.,  in 
Rio  de  Janeiro,  Brazil,  of  86.5  per  cent.,  and  in  Colombo,  Ceylon,  of  84.9 
per  cent.  These  are,  indeed,  most  gratifying  and  absolutely  convincing 
evidences  of  a  possible  further  reduction  under  efficient  and  continued 
antimalarial  efforts,  more  or  less  in  conformity  to  the  principles  of 
malaria  eradication  as  set  forth  in  the  plan  recommended  to  the  National 
Committee  on  Malaria. 

Since  the  results  attained  at  Panama  are  the  classical  illustration  of 
the  truly  marvelous  possibilities  of  malaria  control,  it  may  be  pointed 
out  in  this  connection  that,  comparing  the  malaria  death  rate  of  Panama 
City  during  the  period  1901-1905,  when  it  reached  the  almost  incredible 
figure  of  973.5  per  100,000  of  population,  with  the  average  mortality,  of 
159.9,  of  the  city  during  the  five  years  ending  with  1915,  there  was  an 
actual  reduction  in  the  malaria  mortality  of  Panama  City  during  the 
American  administration,  as  compared  with  the  former  native  or  French 


•The  morbidity  from  malaria  in  the  jails  of  India  has  been  reported  upon  for  many  years.  Combining 
the  returns  for  the  several  provinces,  the  admission  rate  from  malaria  per  thousand  of  average  daily  strength 
has  been  reduced  from  298.5  during  1894-1898  to  199.5  during  1904-1908  and  117.3  during  1914.  The  lowest 
rate  on  record  was  reported  for  the  year  191'2,  when  it  was  105.0,  followed  by  a  rate  of  108.'2  during  1913. 

tThe  general  subject  of  village  and  town  sanitation  in  relation  to  malaria  and  other  diseases  extended  by  the 
mosquito  is  described  in  some  detail  in  "The  Principles  of  Hygiene  as  Applied  to  Tropical  and  Sub-tropical 
Climates,"  by  W.  J.  R.  Simpson,  London,  1908. 

54 


S  TA  TIS  TICAL  COXS  ID  ERA  TIOXS 

administration,  of  813.6  per  100,000  of  population,  equivalent  to  83.6  per 
cent.  In  Sao  Paulo,  Brazil,  during  the  same  period  of  time,  the 
mortality  from  malaria  was  reduced  83.1  per  cent.  In  Manila,  Philippine 
Islands,  it  was  reduced  79.1  per  cent.;  in  Catania,  Italy,  77.9  per  cent.; 
and  in  New  Orleans,  La.,  74.7  per  cent.  Where  so  much  ha;;  been  achieved 
within  so  relatively  short  a  period  of  time,  it  is  apparently  a  foregone  con- 
clusion that  decidedly  better  results  can  be  secured  under  still  more 
advanced  and  well-considered  methods  of  administration  and  control  in 
the  countries  or  cities  where  the  disea.se  at  the  present  time  coutiiuies  to 
prevail  to  a  more  or  less  alarming  degree.  Thus,  in  Kingston,  Jamaica, 
the  malaria  mortality  has  been  reduced  from  248.6  per  100,000  of  poi)ula- 
tion  during  1901-1905  to  99.7  during  1911-1915,  or  59.9  per  cent.;  but 
the  i)resent  rate  for  Kingston  of  99.7  is  in  marked  contrast  to  the 
corresponding  rate  of  20.6  for  Manila,  of  8.8  for  Xew  Orleans  and  of 
only  2.4  for  Havana.  In  the  city  of  Memphis  the  average  malaria 
mortality  during  1900-1904  was  145.0  per  100,000;  during  1910-1914  the 
rate  was  reduced  to  74.2,  or  48.8  per  cent.  Regardless  of  the  gratifying 
decrea.se  in  the  malaria  mortality  of  selected  cities,  it  is  .self-evident, 
in  view  of  the  low  prevailing  rates  of  8.8  for  Xew  Orleans  and  2.4  for 
Havana,  that  the  practical  possibilities  oj complete  malaria  eradication  are 
as  yet  far  from  having  been  attained.  The  certainty,  for  illustration,  that 
the  malaria  mortality  of  Memi)his  is  mat<>rially  increased  by  the  negro 
population,  more  susccj)tiblc  to  malarial  infection  than  the  white  race, 
merely  enipha-sizes  the  national  importance  of  malaria  eratlication,  since, 
on  the  one  hand,  the  negro  element  is  of  the  greatest  economic  impor- 
tance, and  a  measurable  impairment  of  its  physical  efliciencv  must  .seri- 
ously react  upon  the  aggregate  productive  energies  of  the  nation  con- 
sidered as  a  whole;  and,  on  the  other  hand,  the  negro,  on  account  of 
extreme  mobility  and  extensive  migration,  tends,  perhaps  more  than  any 
other  factor,  to  s[)read  the  disease  from  infected  to  non-infected  localities, 
as  has  well  been  illustrated  in  malaria  outbreaks  in  northern  commu- 
nities where  the  anopheles  mo.scjuilo  is  extremely  common  but  ordinarily 
harmless,  because  of  non-infection. 

Recent  malaria  niortiilily  statistics  for  tliirt\ -four  Aiiicrican  cities  are 
briefly  summarized  in  Table  IV  <»f  the  .Vppendix.  .\ccording  to  this 
table  the  average  malaria  mortality  rate  w;us  reduced  from  8.9  per 
100.000  for  the  five  years  ending  with  1904  to  only  3.2  during  the  ti\e 
years  ending  with  1914.  There  was,  therefore,  an  actual  reduction  «»f 
5.7  per  100,000  of  po|)nlation,  ecjuivalent  to  (54  per  cent.  The  redix- 
tion  was  most  niarke(|  in  Key  West,  where  the  rate  was  reduced  from 
32.5  to  only  2.0,  or  93.8  per  cent,  .\mong  oIIht  conspicuous  aehieve- 
ment.s  are  the  results  secured  in  Wilmington,  N.  ('..  where  the  rule  was 
reduced  81.9  percent.,  and  in  Paducah.  Ky..  where  tlie  rale  wits  mhicetl 
57.2  per  cent.  The  one  suggestive  exception  to  the  rule  of  a  geiuTal 
reduction  throughout  the  coimfry  \va>  Mobile.  Ala.,  wlu-re  the  mortality 

56 


STATISTICAL  CONSIDERATIONS 

from  malaria  during  the  decade  under  review  increased  from  51.6  per 
100,000  during  the  first  five  years  to  60.4  during  the  last  five  years,  or 
17.1  per  cent.* 

The  statistical  evidence  as  regards  the  possibilities  and  future  achieve- 
ments of  malaria  eradication  may,  therefore,  be  considered  absolutely 
conclusive.  The  statistical  method,  however,  can  be  utilized,  to  much 
greater  advantage  than  has  heretofore  been  realized,  in  the  scientific  study 
of  the  geographical  distribution  of  the  disease  and  such  elementary  con 
siderations  as  age,  sex,  race  and  occupation  in  their  relation  to  climate, 
soil,  topography,  etc.  In  the  United  States  the  mortality  from  malaria 
falls  chiefly  upon  the  earlier  ages,  but  the  morbidity  often  seriously  im- 
pairs social  and  economic  efficiency  in  adult  life. 

Malaria  also  complicates  many  other  diseases,  even  pregnancy  and 
surgical  operations.  Malaria  is,  therefore,  a  much  more  important 
problem  than  is  generally  recognized  by  the  public,  more  or  less 
indifferent  to  its  occurrence,  upon  the  false  assumption  that  chills 
and  fevers  have  to  be  endured  as  a  matter  of  course  and  in  general  are 
of  no  particular  medical  significance.  The  investigations  which  have 
been  made  by  the  Rockefeller  Foundation  and  the  United  States  Public 
Health  Service  and  the  conservative  estimates  as  regards  the  economic 
loss  arrived  at  by  Prof.  L.  O.  Howard  and  the  equally  important  and  sug- 
gestive observations  on  the  mortality  and  cost  of  malaria  by  Sir  Ronald 
Ross  tend  to  emphasize  the  economic  aspects  of  malaria  eradication 
and  the  lamentable  economic  waste  sustained  by  a  given  population  or 
section  in  consequence  of  an  excessive  incidence  of  malarial  disease. 

The  differential  diagnosis  of  malaria  is,  however,  exceedingly  complex. 
Malaria  complicates  so  many  other  important  diseases  that  in  infected 
sections  it  is  rarely  absent,  at  least  in  a  latent  form.  Its  relation  to 
nephritis  has  been  admirably  described  by  William  Sydney  Thayer,  in 
1908.  It  is  a  well-known  fact  that  the  mortality  from  Bright's  disease 
is  much  higher  among  the  colored  population  of  the  Southern  States  than 
among  the  whites,  a  condition  which  in  a  measure  must  be  ascribed  to 
malarial  infection. 

The  subject  of  blackwater  fever  lies  outside  the  present  discussion. 
Malarial  hematuria,  or  hemoglobinuric  fever,  is  of  a  much  lesser  degree 
of  frequency  occurrence  in  the  Southern  States  at  the  present  time  than 
in  former  years.  According  to  Craig,  "Hemoglobinuric  fever  has  no 
etiological  connection  with  the  malarial  fevers,"  but  he  includes  a  brief 
discussion  of  the  disease  in  his  treatise  on  the  malarial  fevers,  for  the 
reason  that  "the  disease  most  frequently  occurs  in  malarious  regions 
and  very  often  in  the  subjects  of  malarial  infection."  He  points  out 
that,  like  kala-azar,  "this  disease  has  long  been  considered  as  due 
to  malarial  infection,  but  the  more  we  inquire  into  its  etiology,  its 


♦During  very  recent  years  the  malaria  death  rate  of  Mobile  has  decreased  as  follows:  1911,  77.8;  191*2 
67.1;  1913,  53.1;  and  48.6  during  1914. 


5(5 


S  TA  TIS  TICAL  CONSIDER  A  TIOXS 

distribution,  symptomatology  and  pathology,  the  more  must  we  become 
convinced  that  the  malarial  nature  of  tiie  condition  is  far  from  certain, 
and  that  the  evidence  points  to  it  being  a  separate  disease  entity,  in  all 
probability  caused  by  a  hitherto  undiscovered  organism."  This  con- 
clusion, however,  is  strongly  opposed  by  Drs.  Decks  and  James  in  their 
Report  on  Hemoglobinuric  Fever  in  the  Canal  Zone,  published  in  1911. 
On  the  basis  of  "230  cases  subjected  to  critical  analysis,  the  authors 
conclude  that  "The  amount  of  previous  malaria,  whether  recent  or 
remote,  determines  the  prevalence  of  hemoglobinuric  fe\cr,  and  from 
these  conclusions  it  is  very  evident  that  malaria  is  a  predisposing  factor 
of  great  importance  in  hemoglobinuric  fever."  The  subject  of  black- 
water  fever  in  the  tropical  African  dependencies  of  Great  Britain  is 
annually  reported  upon  to  Parliament  in  considerable  detail,  suggestive 
of  corres{)onding  sjiccial  investigations  in  excci)tionally  infected  locali- 
ties in  the  United  States.  An  exceedingly  valual)le  scientific  contril)U- 
tion  to  the  subject  of  blackwater  fever  is  a  report  by  ('apt.  S.  R. 
Christophers  and  Dr.  C.  A.  Bentley,  of  the  India  medical  service.  i)ub- 
lished  as  "Scientific  Memoir  Xo.  3.5"  of  the  Medical  and  Sanitary 
Departments  of  the  Government  of  India,  in  ]!)()!>.  The  results  of  this 
investigation  are  summarized  in  the  statement  that  if  the  conclusions 
as  regards  the  malarial  origin  of  blackwater  fever  are  correct,  "the 
profjhylaxis  of  the  condition  is  simply  the  f)revention  as  far  as  possible 
of  malarial  infection,  and  the  i)rompt  and  efhcient  treatment  of  this 
di.sea.se,  with  the  view  to  prevent  the  occurrence  of  relapses."  The 
point  of  view  that  excessive  quinini/.ation  is  a  cau.se  of  blackwater 
fever  is  not  accepted,  but,  quite  to  the  contrary,  it  is  held  that  the 
systematic  use  of  (|uinine  is  more  or  less  effective  for  propliylactic 
I)urposes.  A  very  useful  general  treatise  on  blackwater  fe\'er  is  l)y 
A.  G.  Newell,  M.  D.,  late  special  deputy  health  officer  of  the  Bombay 
Municipality,  etc.,  in  which  blackwater  fe\-er  is  defined  as  "bilious 
malignant  tertian  ague,"  and  the  prophylactic  treatment  advised  is  a 
well-considered  method  of  (|uininizali<ni.  cornbincd  with  protection 
against  mos(iuitoes  to  safeguard  the  jjatient  against  reinfection. 

The  a.scertaimnent  of  the  true  rate  of  incidence  of  malaria  in  a  given 
area  is  of  the  first  iriiporlatice,  since  there  is  entirely  too  nuich  reliance 
uj)on  general  data,  which  are  more  or  less  misleading  and  inconclusive. 
Thus,  for  illustration,  the  malaria  mortality  rate  of  the  United  Slates 
registration  area  of  iM  per  1()(),()()()  of  |)opulation  is  absolutely  incon- 
clusive; whereas  the  excessive  mortality  from  malaria  in  the  south- 
eastern river  counties  of  Missctiiri  of  KJS.H  is  a  lru<'  measure  of  the  1«kmiI 
imi)ortance  of  the  malaria  j)roblcm  and  the  al>s<»lulc  urgency  of  «'lTcctive 
methods  of  era<lieation  and  control.  Kven  in  that  particular  area, 
limited  to  only  seven  <-ou>ilies,  the  rate  is  as  low  as  (54.1  in  Mississippi 
County  and  as  high  as  «..'!)(;. 7  in  Dunklin  Comity;  in  fact,  in  these 
very  counties,  the  rale  of  lo<al  incidenc*-  will  l»c  found  to  vary  widely 
by  towns,  or  settlements  or  drainage  districts,  and  comparatively  nearby 


S  TA  TIS  TICAL  COXSIDERA  TIONS 

sections  may,  on  the  one  hand,  be  relatively  free  from  the  disease  and, 
on  the  other,  subject  to  an  exceedingly  high  rate  of  frequency* 

All  local  investigations  or  malaria  surveys  to  be  scientifically  conclusive 
require  to  be  made  with  reference  to  climatoiogical  and  topographic  con- 
siderations. In  the  Southern  States  the  highest  mortality  from  malaria 
prevails,  as  a  rule,  during  the  month  of  September,  as  regards  both  the 
white  and  the  colored  population,  and  the  lowest  rates  of  frequency  pre- 
vail generally  during  the  month  of  February,  after  proper  correction  is 
made  for  the  variations  in  the  length  of  the  months.  In  Havana,  how- 
ever, the  maximum  mortality  from  malaria  occurs  in  July,  and  the 
minimum  in  the  month  of  February;  whereas  in  the  Panama  Canal 
Zone  the  maximum  rate  prevails  in  July,  and  the  minimum  rate  in  April,  t 

The  correlation  of  malaria  to  meteorological  conditions  has  been 
attempted  with  a  varying  degree  of  success.  There  are  reasons  for  believ- 
ing that  there  is  no  specific  correlation  conforming  to  the  principle  of  a  gen- 
eral natural  law,  but  that  rather  when  such  a  correlation  is  found  appar- 
ently to  exist  it  is  interdependent  with  local  conditions.  A  minute  analysis 
of  the  meteorological  facts  is,  therefore,  absolutely  essential,  if  the  conclu- 
sions arrived  at  shall  square  with  the  conception  of  scientific  accuracy. 
In  Manaos,  Brazil,  +  for  illustration,  a  maximum  malaria  frequency  coin- 
cides with  a  minimum  rainfall,  which  is  in  marked  contrast  to  the  expe- 
rience observed  in  other  sections  of  the  world.  It  is  self-evident  that 
mere  rainfall  as  such  can  not  be  a  direct  causative  factor,  but  that  it  is 
rather  the  opportunity  provided  for  the  breeding  of  the  anopheles  mos- 
quito, which  tends  directly  to  increase  the  malaria  death  rate.  When  the 
rain  falls  in  very  large  quantities  during  comparatively  short  periods  of 
time,  the  very  excess  in  rainfall  may  in  itself  be  the  means  of  destroying 


*0f  special  interest  in  this  connection  are  the  Soil  Surveys  of  Pemiscot  County,  published  by  the  United 
States  Bureau  of  Soils  in  1912,  of  Stoddard  County,  published  in  1914,  and  of  Dunklin  County,  published  in  1916. 
Also  the  Special  Reports  on  the  Little  River  Drainage  District  of  Missouri,  by  Isham  Randolph,  Consulting 
Engineer,  Chicago,  111.,  and  a  Preliminary  Report  on  the  St.  Francis  Valley  Drainage  Project  in  Northeastern 
Arkansas,  by  Arthur  E.  Morgan,  Office  of  Experiment  Stations,  Washington,  D.  C,  1909.  For  another 
excellent  illustration  of  the  practical  value  of  thoroughgoing  local  malaria  studies,  reference  may  be  made  to  the 
address  on  Malaria  in  Greece,  by  Sir  Ronald  Ross,  published  in  the  Smithsonian  Report  for  1908. 

fSee  in  this  connection  special  publication  No.  3,  "The  Mortality  of  the  Western  Hemisphere,"  published  by 
The  Prudential  Insurance  Company  of  America,  on  the  occasion  of  the  Panama-Pacific  International  Exposition, 
Sau  Francisco,  1915. 

{RAINFALL  AND  MALARIA  MORTALITY 

Manaos,  Brazil,  1907-1914  Panama  City,  1908-1914 

Month                         Rainfall  Deaths  from  Percentage  Rainfall          Deaths  from  Percenta^tt 

(inches)  Malaria  Distribution*  (inches)  Malaria  Distribution* 

January 8.4  253  6.3  0.9                    80  9.6 

February 7.8  293  8.0  0.9                    63  8.3 

March 10.0  328  8.2  0.4                    49  5.8 

April 8.5  303  7.8  3.1                    41  5.1 

May 7.0  345  8.6  9.1                   53  6.3 

June 3.4  398  10.3  6.8                   71  8.8 

July 1.3  479  11.9  7.2                    84  10.0 

August 1.1  472  11.8  8.3                    80  0.6 

September 1.7  365  9.4  7.1                    67  8.8 

October 4.0  276  6.9  10.0                   78  9.4 

November 5.2  205  5.3  9.1                    66  8.1 

December 8.6  220  5.5  6.5                  90  10.7 

Total 67.0  3,937  100.0  69.4  822  100.0 

•Adjusted  for  varying  length  of  months. 

58 


STATISTICAL  COXSIDERATIOXS 

breeding-places  of  anopheles  mosquitoes;  and  the  subsequently  rapid 
drying  of  the  soil  and  the  rapid  evaporation  of  the  standing  water  may 
aid  in  reducing  malaria  frequency.  As  a  general  rule,  however,  a  heavy 
average  rainfall,  fairly  normally  distributed  throughout  the  year,  coincides 
with  an  excess  in  malaria  frequency,  provided  the  temperature  condi- 
tions, humidity  and  wind  force  are  all  favorable.* 

The  malaria  death  rate  is  also  materially  modified  by  race  and  the 
migration  of  people  from  non-malarial  countries  to  more  or  less  intensely 
malarial  regions.  There  can  be  no  question  of  douljt  but  that  some  form 
of  natural  immunity  or  protection  against  malaria  is  acquired,  if  not  other- 
wise than  through  the  almost  universal  malarial  infection  in  infancy  in 
countries  subject  to  an  extremely  high  malaria  rate,  f  Race  is,  therefore, 
of  serious  importance,  as  is  best  illustrated  by  the  data  for  the  southern 
part  of  the  United  States  registration  area,  for  which  the  returns  are 
apj)roximately  trustworthy  and  according  to  which  the  average  malaria 
death  rate  was  8.0  per  100,000  for  the  white  population,  against  tiO.O  for 
the  colored.  The  contrast  is  much  less  marked  in  Cuba,  where  white 
males,  for  illustration,  have  a  malaria  death  rate  of  ^Z'i.'i,  against  a  malaria 
death  rate  for  the  colored  of  31.8,  and  where  the  white  female  malaria 
death  rate  is  16.5,  and  the  colored  27.8.  It  has  been  found  by 
experience  in  the  West  Indies,  particularly  in  Jamaica  and  British 
Guiana,  that  the  coolie  immigrants  from  the  East  Indies  are  exceed- 
ingly liable  to  malaria,  so  nuich  so  that  during  100.5-1!)11,  for 
illustration,  the  East  Indian  population  of  British  Guiana  experienced 
a  malaria  death  rate  of  547.()  per  100,000  of  population.  Since  this 
element  is  imj)orted  solely  for  i)lantation  [)urp()ses  the  impairment  in  labor 
efficiency  resulting  from  malaria  must  reach  extraordiii;iry  prijportions, 
which,  unfortunately,  are  imperfectly  realized  or  indifferently  regarded 
by  the  governments  and  the  i)lantation  element  responsible  for  malaria 
eradication  and  health  i)rotcction  otherwise  in  the  countries  referred  to. 
As  a  general  statcineiil  it  may  l)e  asserted  that  most  of  the  hospital  pop- 
ulation in  the  island  of  Jamaica,  on  account  of  malaria,  consists  of  East 
Indians,  although  this  element  constitutes  but  a  relatively  small  propor- 
tion of  the  plantation  labor  of  the  island.  In  contrast,  the  remarkable 
achievement  in  liealtli  promofion  and  sanitation  in  Hawaii  is  the  result 
of  active  and  energ<'tic  administrative  mejLsures  in  coordination  with 
the  efforts  of  the  sugar-i)lanters  of  the  island,  which  have  reduced  the 
death  rate  from  all  causes  and  from  such  diseases  as  most  commonly  pre- 
vail among  the  immigrant  class  to  normal  and  cxcn  subnormal  propor- 
tions. 

These  very  general  statistical  considerations  are  merely  inlcntled  to 
emphasize   the   urgency   and   practical   usefulness  of  a    lliorough   and 

•The  annual  variations  i>f  niiiluria  witli  s|>r)'iii|  rrfrrrnrr  to  rninrnll  linve  hrrii  r.  i-tI.  .|  ui...ii  in  aom*  dftailin 
111.    I"ir«t  Kr|K>rt  on  Malurin  in  HrnKnl.  I.v  Mtt).  A.  I«.  Fry.  M.  D.  <«l.  ulla.  l»l<. 

tSrc  A  ri.a  for  a  .National  C'ominiltcc  on  Ihr  Kra<li<ation  .f  M  .1  .n..  Vnr  ihU.,n>  U^,i,<;it  and  Surftrt, 
Journal,  Aiiguil.  1010.  (or  ujrful  adililiunnl  lUitiatiral  iiiformntion. 

59 


S  TA  TIS  TJCAL  CONSIDERA  TIONS 

qualified  analysis  of  the  mortality  and  morbidity  from  malaria  through- 
out that  portion  of  the  world  in  which  the  disease  is  known  to  exist  to  a 
more  or  less  serious  degree.*  The  practical  importance  of  malaria 
eradication  is  so  perfectly  obvious  that  it  should  not  require  an  extended 
argument  in  support  of  the  plea  and  the  ])lan  of  the  National  Committee 
on  Malaria  in  the  furtherance  of  the  implied  obligation,  governmental 
or  otherwise,  contained  in  the  resolution  adopted  by  the  Second  Pan- 
American  Scientific  Congress.  It  is  not  going  too  far  to  say  that  malaria 
eradicatioyi  is  essentially  a  labor  problem  of  the  first  importance;  that  an 
enormous  amount  of  labor  inefficiency  due  to  malaria  continues  to  hinder 
the  progress  of  semi-tropical  and  tropical  countries,  which,  if  brought 
under  control  and  completely  done  away  with,  must  needs  assist  pro- 
foundly in  the  reclamation  of  the  tropical  regions  for  the  practical  needs 
of  the  world  at  large,  j  What  has  been  done  in  this  direction  by  the 
United  Fruit  Company  in  the  gradual  eradication  of  malaria  from  its 
plantations  and  from  among  its  white  employees  from  the  United  States, 
required  for  administrative  purposes,  is  deserving  of  special  consideration 
as  perhaps  the  best  illustration,  next  to  the  classical  results  secured  in 
Panama,  of  the  practical  achievements  and  future  possibilities  of  malaria 
eradication  in  the  western  world.  %  Even  under  present  conditions,  regard- 
less of  the  progress  which  has  been  made  in  Banes,  Cuba,  49  per  cent, 
of  the  cases  treated  in  the  hospitals  of  that  company  are  on  account  of 
malaria,  in  Guatamala  the  proportion  was  42  per  cent.,  and  in  Tela, 
Honduras,  39  per  cent.  (1915).  Malaria  has  not  been  completely  eradi- 
cated from  the  Isthmus  of  Panama,  nor  is  it  likely  that  for  a  long  time  the 
disease  will  be  entirely  eradicated  from  any  section  of  the  world;  but  its 
complete  eradication  is  an  ideal  which  need  not  disturb  those  who  are 
working  for  the  attainment  of  a  material  modification  of  and  improve- 
ment in  existing  conditions.  There  is  malaria  in  practically  every  state 
in  the  Union  and  in  practically  every  country  of  the  world.  Wherever 
anopheles  mosquitoes  exist,  there  possibilities  of  malarial  outbreaks  exist 
also,  provided,  of  course,  climatological  conditions  are  favorable.  The 
best  practical  illustration  of  this  conception  of  malaria  eradication  and 
control  as  a  world  problem  is  to  be  found  in  the  experience  which  has 
resulted  from  the  European  War,  and  which,  particularly  in  the  case  of 


•It  is  an  error  to  assume  that  malaria  prevails  throughout  the  tropics,  as  pointed  out  in  a  note  of  the  Journal 
of  the  American  Medical  Association  under  date  of  April  25,  1914.  "According  to  the  report  by  Maj.  Brooke,  of 
the  United  States  Army,  Cebu  in  the  Philippines  is  free  from  malaria,  although  the  anopheline  mosquito  has 
been  found  there,  and  it  is  surrounded  by  the  zones  in  which  malaria  is  epidemic.  Brooke  refers  to  the  sugges- 
tion by  Manson  'that  there  are  some  places  free  from  malaria  yet  surrounded  by  epidemic  zones,  as  in  the  case 
of  Cebu,  because  in  that  particular  area  food  conditions  for  the  mosquito  can  exist  which  are  inimical  to  the 
growth  of  parasites  in  their  bodies.'"     (See,  also,  "The  Tropics,"  by  C.  R.  Enock,  New  York,  1915.) 

tThe  relation  of  malaria  to  agriculture  has  been  made  the  subject  of  a  special  investigation  by  the  Bureau  of 
Entomology,  published  by  the  United  States  Department  of  Agriculture.  In  Madison  Parish,  La.,  it  was  found 
that  twelve  families  cultivating  286  acres  of  land  lost  an  aggregate  of  88  weeks'  time  during  the  crop-growing 
season  on  account  of  malaria,  or  more  than  seven  weeks  per  family.  The  financial  loss  was  estimated  as  $24 
per  family. 

|^'or  a  full  account  of  the  sanitary  achievements  of  the  United  Fruit  Company,  see  "Conquest  of  the 
Tropics,"  by  Frederick  Upham  Adams  (New  York,  1914),  and  the  annual  reports  of  the  company's  medical 
department  for  the  years  1909-1915. 

60 


.S  TA  TIS  TICAL  COXSIDERA  TIOXS 

France  and  the  Mediterranean  countries,  has  resulted  in  serious  complica- 
tions as  regards  the  medical  treatment  of  the  wounded  and  the  phj'sical 
efficiency  of  the  forces.  With  commendable  foresight,  therefore,  the 
British  War  Office  has  issued  an  admirable  handbook  on  "Some 
Medical  Diseases  in  the  Mediterranean  War  Area,"  in  which  malaria 
is  given  the  most  extended  consideration  of  all  the  diseases  con- 
sidered in  detail.  More  important,  therefore,  than  cerebrospinal  fever, 
typhus  fever,  paratyphus,  relapsing  fever,  heat-stroke  or  dysentery  is 
malaria  in  the  southern  war  area,  and,  as  well  said  in  the  work  referred  to, 
"A  considerable  number  of  cases  of  malaria,  that  mod  Protean  of  all 
diseases,  has  occurred  at  Cape  Hellas  and  Suvla  Bay."  Malaria  is  not 
likely  to  be  of  deciding  importance  in  the  present  European  War,  but  it 
may  under  given  conditions  prove  as  serious  a  factor  as  regards  local 
conflicts  as  the  disease  unquestionably  constitutes  in  the  progress  or 
decay  of  given  localities  or  states. 

The  importance  of  malaria  as  a  factor  in  military  efficiency  has  been 
recognized  l)y  all  authorities  on  military  hygiene.  The  early  United 
States  Army  experience,  particularly  in  the  Southern  States,  proves  con- 
clusively the  extensive  and  serious  prevalence  of  intermittent  and  remit- 
tent fevers  and  its  relation  to  the  resulting  inefficiency  or  incajjacity 
of  the  troops.  As  early  as  1808,  Edward  Cutbush,  M.  D.,  of  the  United 
States  Xavy,  in  his  observations  on  the  means  of  i)reserving  the  health 
of  the  soldiers  and  sailors,  states  that  "\\'e  learn  frt)m  experience  that 
fevers  are  little  known  in  rough,  hilly  countries,  where  water  flows  with 
a  rapid  course;  while  we  likewise  know,  that  they  are  common  in  low  and 
champaign  countries,  where  water  stagnates,  or  has  only  a  sluggish 
motion:  indei)en(ieiit  of  which,  those  situations,  which  are  in  the  neigh- 
borhood of  swamps  or  near  oozy  banks  of  large  rivers,  have  always  l)een 
observed  to  be  particularly  liable  to  such  diseases."  Even  more  sug- 
gestive arc  the  "Medical  Sketches  of  the  Campaigns  of  181'-2-1814,"  by 
James  Mann,  M.  I).,  published  in  Dcdiiam,  ISUi.  These  sk(>lch('s  in- 
clude obser\ali(»ns  on  the  extensive  and  serious  prevalence  of  inter- 
mittent and  remittent  fevers  in  Burlington,  ^'l.,  and  on  the  Niagara 
frontier.  Attention  is  directe(l  lo  the  iniportance  of  drainage  and 
(•ulti\'af i«»n  in  their  rdalinn  to  l'e\-er  occurrcnc**,  the  statement  being, 
in  i)art,  thai  "In  })ri)j)()rl  ion  as  (•nili\ali()n  of  the  earth  is  exiendcfl  by 
op<'ning  the  forests  and  draining  the  lands,  so  will  climate  be  impr<)\<'<i. 
and  its  end<'mic  diseases  <lisappear.  The  heavy  fogs  of  lakes  and  large 
rivers,  which  are  impeded  and  suspended  over  their  borders  by  wikxI- 
lands  until  a  late  hour  of  the  t\;\\\  abstract  from  the  body  its  \ital  heaf. 
and  snbj<'cl  the  inhabilatils  lo  iiilcrmil  f  cut  fc\'ers,  and  other  anlnninal 
diseases,  as  dysentery  and  diarrhea.  They,  however,  are  less  fre(juent 
at  those  jjoints,  on  the  lake  sh(»res,  where  cultivation  has  made  some 
progress, .-ind  iiaxc  disap|)ean*d  where  the  lands  are  extensi\-ely  impro\<'d. 
'i'hese  autumnal  diseases,  which  are  now  considered  endemic  in  new 
settlements  on  the  frontiers,  will  vanish  as  the  forests  are  snl)dMcd,  :uu\ 

61 


S  TA  TIS  TICAL  CONSIDER  A  TIONS 

the  marshes  and  swamps  drained;  while  the  husbandman  will  be 
remunerated  by  a  twofold  reward,  higher  degrees  of  health  as  well  as 
accumulation  of  wealth." 

These  observations  by  a  military  surgeon  of  extensive  experience  are 
fully  sustained  by  the  results  of  a  thorough  statistical  analysis  of  the 
sickness  and  mortality  in  the  United  States  for  the  period  1819-1839, 
by  Thomas  Lawson,  M.  D.,  Surgeon-General,  published  in  1840.  These 
early  statistical  investigations  suggest  an  equally  extended  analysis  of 
our  more  recent  army  experience,  with  special  reference  to  the  different 
army  posts  and  fields  of  military  occupation  in  tropical  territory.  The 
statistics  of  fever  morbidity  and  mortality  during  the  Civil  War  form  an 
important  contribution  to  medical  history  and  experience,  and  even 
at  the  present  time  the  observations  on  Malarial  Influence  on  Army  Life 
and  Efficiency  by  Brigadier-General  William  A.  Hammond,  Surgeon- 
General,  United  States  Army,  published  in  1863,  are  of  value,  regardless 
of  the  fact  that  they  rest  upon  fundamentally  erroneous  assumptions 
as  to  the  nature  of  malarial  disease  and  its  then  unknown  transmission 
from  insects  to  man. 

The  truly  enormous  progress  which  has  been  made  in  malaria  eradica- 
tion and  control  during  the  long  intervening  period  of  years  is  reflected 
in  the  timely  observations  on  the  subject  by  Edward  L.  Munson,  M.  D., 
late  Chief  Medical  Department,  United  States  Army,  in  his  treatise  on 
"The  Theory  and  Practice  of  Military  Hygiene,"  published  in  1901. 
The  observations  of  Dr.  Munson,  which,  it  requires  to  be  considered, 
precede  the  practical  application  of  the  discovery  by  Sir  Ronald  Ross 
of  the  insect  transmission  of  malaria,  are  briefly  summarized,  with 
special  reference  to  army  experience,  as  follows: 

Malaria  has  ravaged  armies  in  every  age  and  climate,  and  has  frequently 
modified  military  operations  or  brought  about  their  failure.  Rome  was  saved 
from  capture  by  malarial  fevers,  which  so  scourged  the  besieging  Gauls  under 
Brennus  as  to  cause  their  retreat.  In  the  year  208,  the  Roman  army  in  Scotland 
lost  50,000  men  out  of  a  total  of  80,000  from  this  cause.  No  military  disaster 
caused  by  malarial  infection  was  more  complete,  however,  than  that  of  the 
British  expedition  to  the  island  of  Walcheren,  in  1809.  On  this  occasion  it  has 
been  said  that  the  British  were  conquered  before  the  battle.  Out  of  an  effective 
force  of  39,219  there  succumbed  to  the  fever,  between  August  28th  and  Decem- 
ber, no  less  than  23,175  men,  while  after  the  return  to  England  there  were  11,503 
additional  cases.  But  217  men,  during  this  disastrous  expedition,  were  kiUed 
by  the  enemy.  In  the  Seminole  War,  in  Florida,  our  troops  suffered  severely 
from  malarial  infections.  In  the  French  army  before  Sebastopol  there  were 
20,623  cases,  with  2,179  deaths.  In  the  Union  forces,  during  the  Civil  War, 
there  were  1,314,744  cases  of  malaria,  with  10,062  deaths,  giving  a  mortality  of 
3.92  per  thousand  strength.  "But  though  the  mortality  from  these  fevers  was 
comparatively  light,  their  influence  in  detracting  from  the  efficiency  of  the  arrny 
was  very  great" — as  well  as  largely  influencing  the  rates  of  discharge  for  dis- 
ability on  account  of  resulting  anemia  and  chronic  malarial  poisoning.  The 
so-called  "Chiekahominy  fever"  was  particularly  severe  in  its  effects.  Malarial 
fevers  prevailed  in  the  French  army  during  the  Italian  War  and  the  occupation 
of  the  Papal  States.  Ashmead  states  that  5,995  Japanese  soldiers,  sent  to 
Formosa  in  1873,  furnished  6,105  admissions  to  hospital,  for  continued  malarial 
fevers,  in  a  single  year.  In  the  French  expedition  in  Madagascar,  in  1895,  out 
of  a  force  of  22,850  men — combatants  and  carriers — there  were  7,498  deaths 

62 


S  TA  TIS  TIC  A  L  COXS  ID  ERA  TIOXS 

from  disease;  a  mortality  of  about  33  per  cent.  Nearly  aU  the  deaths  were  from 
malarial  fevers.  During  this  expedition  only  7  men  were  killed  by  the  enemy 
and  but  94  wounded.  In  the  same  year,  a  Spanish  expedition  in  the  Philippine 
Islands  was  scourged  by  malarial  fever.  During  the  last  insurrection  in  Cuba, 
the  Spanish  forces  were  largely  depleted  by  malarial  infections  of  a  severe  type ; 
the  admissions  to  hospital  for  this  cause,  during  the  year  1897,  amounting  to 
420  per  thousand  strength.  In  1898,  after  the  capture  of  Santiago,  one-half  of 
our  forces  in  Cuba  were  incapacitated  for  duty  at  the  same  time  by  reason  of 
malarial  fevers.  This  grave  condition  of  affairs  evoked  an  appeal  to  the  War 
Department,  signed  by  all  the  officers  of  higher  rank,  for  an  immediate  remo\'al 
of  these  troops  to  a  more  healthy  locality — using  the  sentence:  "This  army 
must  be  moved  or  perish." 

Dr.  Munson  directed  attention  to  the  fact  that  since  the  Civil  War  tlie 
admissions  for  malaria  for  the  entire  army  had  been  reduced  from  a 
maximum  of  793.8  per  1,000  strength  in  1868  to  78.9  per  1,000  in  1807. 
In  consequence  of  the  Spanish  American  War,  of  1898,  the  admission 
rate  on  account  of  the  exposure  to  malarial  infection  in  the  tropics  was 
increased  to  694.6  per  1,000.  More  recent  statistics  for  the  United 
States  Army  and  Xavy  are  briefly  summarized  in  the  two  tables  following: 

MORBIDITV  FROM  MALARIA,  UNITKD  STATES  ARMY,  1901-1915 
Rato  per  1.000  Mean  Strength 

1901 380.4  1906 122.4  1911 39.6 

1902 272.3  1907 88.7  1912 51.7 

1903 201.2  1908 59.6  1913 33.8 

1904 102.3  1909 49.4  1914 29.4 

1905 122.3  1910 42.2  1915 25.2 

MORBIDITY  FROM  MALARIA.  UNITED  STATES  NAVY'.  1901-1915 
Kat»'  per  1,000  Mean  Strength 

1901 41.4  1906 43.6  1911 12.1 

1902 45.1  1907 31.4  1912 11.6 

1903 32.8  1908 21.8  1913 12.1 

1904 39.1  1909 18.3  1914 17.4 

1905 24.8  1910 11.8  1915... 17.7 

The.se  statistics  reflect  the  direct  influence  of  governmental  policy 
ba.sed  upon  the  modern  knowledge  of  the  insect  transmission  of  malarial 
infections.  The  increase  in  the  navy  malaria  morbidity  rate  during  the 
last  two  years  is  accounted  for  by  the  naval  operations  in  Mexico  and 
the  West  Indies.  The  army  malaria  death  rate  has  been  reduced  from 
1.35  per  1,000  in  1900  to  only  0.0^2  in  1915.  In  the  navy  the  mortality 
from  malaria  siticc  1901  lias  been  negligible. 

"^riie  j)liysical  cflicii  iicy  of  an  army  is  measured  or  determined  by  the 
constantly  non-effective  rate,  that  is,  the  j)roportion  of  men  con- 
stantly on  the  sick  list.  The  non-effective  rate  of  the  liiiited  States 
Army  has  been  very  materially  reduced  during  recent  years,  but  the 
ideal  of  .SO  per  1.000  has  not  been  attained.  During  190!).  for  illustra- 
tion, the  non-effective  rate  was  4'-2,  which  according  to  Ilavard  was 
equivalent  to  a  lo.ss  of  14.5  days  from  sickness  or  injury  for  each  soldier, 
in  contrast  to  an  average  loss  of  only  9.7  days  for  the  navy  and  of  10.4 
days  for  the  British  army.  The  practical  significance  of  malaria  as  a 
basic  consideration  in  problems  of  military  efficiency  and  national 
preparedness  therefore  assumes  the  importance  of  a  medical,  economic 
and  military  prol)lem  of  the  first  order. 

08 


STATISTICAL  CONSIDERATIONS 

Table  I 
Mortality  from  Malaria  Throughout  the  World 


WESTERN  HEMISPHERE 

Aggregate 

Country                                                       Period  Population 

Nicaragua 1908-1911  2,180,000 

British  Honduras 1914-1915  88,268 

City  of  Guayaquil,  Ecuador. ...  191 1-1915  420,000 

British  Guiana 1911-1915  1,516,710 

City  of  San  Salvador 1910-1914  324,900 

Venezuela 1908-1912  13,525,191 

Trinidad  and  Tobago 1910-1914  1,715,102 

City  of  Paramaribo,  D.  Guiana.  1908-1912  174,775 

Panama  Canal  Zone 1911-1915  677,792 

Sixteen  Cities  of  Brazil 1909-1913  11,725,980 

Brit.  Leew'd  and  Windw'd  Isls.  1910-1914  1,026,879 

Porto  Rico 1911-1915  4,675,044 

Costa  Rica 1911-1915  1,999,545 

Jamaica 1911-1915  4,317,064 

St.  Thomas,  Danish  W.  1 1911-1915  53,050 

Cuba 1910-1914  11,561,416 

United  States  Reg.  Area 1910-1914  302,835,133 

EASTERN  HEMISPHERE 

Mauritius 1910-1914  1,842,561 

Straits  Settlements 1910-1914  3,596,554 

Zanzibar  Qity 1910-1914  176,320 

Philippine  IsT^ds 1909-1913  29,472,283 

City  of  Freetown,  Sierra  Leone .  1910-1914  170,000 

Hongkong 1911-1915  1,999,524 

Ceylon 1910-1914  20,817,228 

Algiers  (Europeans) 1908-1912  3,712,365 

Spain 1906-1910  96,717,000 

Italy 1909-1913  173,356,885 

Portugal 1905-1909  28,817,465 

UnionofS.  Africa  (Europeans).  1912-1914  4,018,253 

France 1908-1912  197,198,000 

Commonwealth  of  Australia ..  .  1909-1913  22,583,681 

Table  II 


Deaths  from 
Malaria 

15,859 

491 

1,781 

6,385 

1,223 

41,331 

3,754 

257 

949 

12,878 

997 

3,793 

1,251 

2,278 

15 

2,535 

7,859 


21,686 

19,818 

867 

117,139 

428 

1,667 

11,304 

1,768 

10,930 

17,399 

1,874 

141 

2,029 

174 


Kate  p«r 

100,000 
Population 

727.5 

589.7 

424.0 

421.0 

376.4 

305.6 

218.9 

147.0 

140.0 

109.8 

97.1 

81.1 

62.6 

52.8* 

28.3 

21.9 

2.6 


1176.9 

551.Qt 

491.7 

397.5 

251.8 

83.4 

54.3 

47.6 

11.3 

10.0 

6.6 

3.5 

1.0 

0.8 


A  Decade  of  Malaria  Mortality  Reduction  in  Large  Foreign  Cities 


City 

Habana 

St.  Thomas  Is.. 
Rio  de  Janeiro 

Colombo 

Panama  City. . 

Sao  Paulo 

Manila 

Catania 

Kingston 

Calcutta 

Rome 

Port  of  Spain . 
Hongkong .  .  .  . 
Bahia 


Cuba 

Dan.  W.I... 

Brazil 

Ceylon 

Panama 

Brazil 

Philippine  Is. 

Italy 

.Jamaica 

India 

Italy 

Trinidad  .  .  .  . 
China  (Br.).. 
Brazil 


1900-1904 
1900-1904 
1900-1904 
1900-1904 
1901-1905 
1899-1903 
1902-1905 
1899-1903 
1901-1905 
1900-1904 
1899-1903 
1900-1904 
1901-1905 
1899-1903 


Death  Rate 

from  Malaria 

per  100,000 

Population 

49.0 

334.8 

152.9 

244.4 

973.5 

34.3 

98.4 

23.5 

248.6 

676.5 

16.6 

116.3 

126.5 

157.6 


1910-1914 
1910-1914 
1910-1914 
1910-1914 
1911-1915 
1909-1913 
1912-1915 
1909-1913 
1911-1915 
1910-1914 
1909-1913 
1910-1914 
1911-1915 
1909-1913 


Death  Rate 

from  Malaria 

per  100,000 

Population 

2.4 

37.6 

20.7 

37.0 

159.9 

5.8 
20.6 

5.2 

99.7 

291.8 

8.9 

63.9 

83.4 

123.7 


95.1 
88.8 
86.5 
84.9 
83.6 
83.1 
79.1 
77.9 
59.9 
56.9 
46.4 
45.1 
34.1 
21.5 


♦During  these  years  were  recorded  in  Jamaica  as  due  to  "fevers"  without  distiuction  15,658  deaths,  giving 
a  rate  of  362.7  per  100,000  of  population. 

tThere  were,  also,  in  the  Straits  Settlements  during  this  period  23,!J19  deaths  from  undefined  fevers,  giving 
a  rate  of  645.0  per  100,000  of  population. 


64 


S  TA  TIS  TICAL  COXSIDERA  TIOXS 


Table  III 
Mortality  from  Malaria  in  Italy— 1894-1913 


Period 

1894-1898. 
1899-1903. 
1904-1908. 
1909-1913. 


AgEreiirate 
Population 

Deallu  from 
.Malaria 

157,530,358 

69,108 

102,555,072 

58,659 

166,876,011 

28,888 

173,587,368 

17,399 

Rate  per 
100,000  Pop. 

43.9 
36.1 
17.3 
10.0 


Table  IV 

A  Decade  of  Malaria  Reduction  in  Thirty-four  Cities  of  the 

United  States 

1900-1904  1910-1914 

Kate  per  Rate  per  Perctatag* 

AefCrepate  Total  100,t>l>0  Aetp-egate  Toul  100,000                  of 

City  Population  Deaths  Population  Population  Deatha  Population  DecreaM 

Key  West,  Fla 92,33G  30  32.5  102,317  2  2.0  93.8 

Richmond,  Va 439,580  89  20.2  C5C,759  12  1.8  91.1 

Boston,  Mass 2,873,433  29  1.0  3,530,050  5  0.1  90.0 

Providence,  R.  1 924,058  63  6.8  1,170,584  8  0.7  89.7 

Newark,  X.J 1,298,300  51  3.9  1,851,221  7  0.4  89.7 

New  York  City.N.Y.  18,312,405  682  3.7  25,343,167  124  0.5  86.5 

Washington,  D.C...  1,448,810  162  11.2  1.713,879  32  1.9  83.0 

Jersey  City,  N.  J 1,084,695  38  3.5  1,408,879  8  0.6  82.9 

Toledo,  Ohio 697,791  35  5.0  883,489  8  0.9  82.0 

Wihnington,  X.  C .  .  .  109,910  245  222.9  134,073  54  40^  81.9 

Bridgeport,  Conn ..  .  387,740  23  5.9  544,995  6  "Tl  81.4 

Baltimore.  Md 2,597,020  172  6.6  2,847,798  36  1.3  80.3 

Jacksonville,  Fla.  ..  .  155,886  266  170.6  323,646  110  34.0  80.1 

San  Antonio.Texas.  .  312,270  178  57.0  531,476  69  13.0  77.1 

New  Orleans,  La 1,490,336  518  34.8  1,75.3,479  154  8.8  74.7 

New  Haven,  Conn. .  .  567,115  56  9.9  696,624  18  2.6  73.7 

Chicago,  III 9,006,276  96  1.1  11,481,145  39  0.3  72.7 

Kansas  City,  Mo 897,475  GO  6.7  1,329,298  28  2.1  68.7 

Indianai)oIi.s,  Ind..  .  .  928,845  51  5.5  1,235,255  22  1.8  67.3 

Nashville,  Tenn 415,175  128  30.8  563,397  68  12.1  60.7 

Alexandria,  Va 73,480  12  16.3  77,538  5  6.4  60.7 

St.  Ixjuis.  Mo 2,372,644  275  11.6  3,560,1.35  162  4.6  60.3 

riiducah,  Ky 100,715  178  176.7  117.49S  89  75.7  57.2 

l'liiladeli)hia.  Pa.  .  6,737,795  76  1.1  8,030,511  40  0.5  54.5 

Charleston,  S.  C.  ..  .  282,220  176  62.4  297,544  92  30.9  50.5 

San  Franci.sc-o.Calif. .  1,792,101  50  2.8  2,167,443  31  1.4  50.0 

Memphis,  Tenn 528,245  766  145.0  685,525  509  74.2  48.8 

AtlauUi,  Ga 496,051  51  10.3  836,074  40  5.5  46.6 

Savannah,  Ga 296,243  392  132.3  .332,093  261  78.6  40.6 

Kvansvillo,  Ind 305,723  40  13.1  352,075  28  8.0  38.9 

St.  Jo.seph,Mo 336,855  19  5.6  400,679  17  4.2  25.0 

Norfolk,  Va 294,486  85  28.9  401,396  92  22.7  21.5 

b.uisville,  Ky 1.015.310  53  5.1  1,149,419  47  4.1  19.6 

Mobile,  Ala 195,.560  101  51.6  268.100  162  60.4  -hH.!* 

Thirty-four  cities. ..  .  58,896,884  5,846  8.9  76,786,561  2.491  3.2  64.0 
'Increaac. 


65 


THE  PRUDENTIAL 
INSURANCE  COMPANY  OF  AMERICA 

Incorporated  under  the  laws  of  the  State  of  New  Jersey 


FORREST  F.  DRYDEN,  President 

HOME  OFFICE,  NEWARK,  NEW  JERSEY 


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